IIIIIIIIIIIIIIIIIIIIIIIIII!

v)
.‘;1\\5
a) i

 

ﬁrm
I *' maﬁa“

This is to certify that the
dissertation entitled

HEALTH SOCIAL MOVEMENTS IN A TRANSNATIONAL
CONTEXT: RACING AROUND THE WORLD FOR A CURE

presented by
Lori B. Baralt

has been accepted towards fulﬁllment
of the requirements for the

Ph , D . degree in Sociology

 

 

("I 6/ '

Major Professor’s Signature

iéﬂézr)?’

ate

MSU is an Aﬂirmatm Action/Equal Opportunity Employer

 

-¢-h-l-l-I-l-I-l-

--.--n--a—a-.-.--a-.-

.I-I-o--L-O-I-l-I-I-I-I-l-I-I-I-C-l-l-O-I-0-l-I-v-h-I-l-I-O-O-l-D-I-‘-1-I-h-l-l

 

PLACE IN RETURN BOX to remove this checkout from your record.
TO AVOID FINES return on or before date due.
MAY BE RECALLED with earlier due date if requested.

 

DATE DUE DATE DUE DATE DUE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5/08 K:/Prolecc&Pres/ClRC/DateDue.indd

HEALTH SOCIAL MOVEMENTS IN A TRANSNATIONAL CONTEXT:
RACING AROUND THE WORLD FOR A CURE

By

Lori B. Baralt

A DISSERTATION

Submitted to
Michigan State University
In partial fulﬁllment of the requirements
For the degree of

DOCTOR OF PHILOSOPHY
Sociology

2009

ABSTRACT

HEALTH SOCIAL MOVEMENTS IN A TRANSNATIONAL CONTEXT:
RACING AROUND THE WORLD FOR A CURE

By

Lori B. Baralt
Beginning in the 19908, the two largest, most inﬂuential and well-known breast cancer
advocacy organizations in the US, Susan G. Komen for the Cure and the Avon
Foundation, began expanding biomedical breast cancer advocacy internationally.
Focusing on these organizations’ development within the US and subsequent expansion,
particularly within Puerto Rico and Italy, within this qualitative intrinsic case study, I
draw from medical sociology and social movement theory to analyze how and why these
breast cancer advocacy organizations have expanded globally, how advocacy strategies
and tactics have been incorporated into diverse political and cultural contexts, and how
corporate sponsors, particularly pharmaceutical and medical technology companies, and
medical professionals have participated in the organizations’ expansion to shed light on
the role of transnational health advocacy organizations in processes of biomedicalizaiton
and the political economy of health and illness on an international scale. I ﬁnd that
SGKC, as an elite advocacy organization, and the Avon Foundation, as the outgrth of
a corporation, expanded based on a corporate model of market expansion. These
organizations socially constructed breast cancer as a critical global epidemic requiring

increased awareness and education about breast cancer, thereby positioning their

approach to breast cancer as the solution to the problem and legitimizing their expansion
efforts. To expand beyond the US, SGKC and the Avon Foundation developed
transnational mixed actor coalitions, in which they partnered with governmental agencies,
medical professionals and research centers, and corporations, blurring the boundaries
between the non-proﬁt social sector and various sectors of society. Implementing only
minor political and cultural adaptations to their biomedical advocacy strategies, SGKC
and the Avon Foundation, through their global events, campaigns and programs, are
facilitating processes of biomedicalization through messages of awareness and education,
the dissemination of medical information, the promotion of “surveillance medicine,” and
the production of new “at-risk” and medical consumer identities. Finally, by promoting
cause-related marketing and corporate sponsorship and involvement in advocacy events
internationally, SGKC and the Avon Foundation are playing a signiﬁcant role in the
global political economy of health and illness by promoting corporate and consumer-

oriented solutions to health problems.

To my mom, my inspiration

iv

ACKNOWLEDGEMENTS

Throughout my time as a graduate student I have been extremely fortunate to have the
support of faculty, ﬁ'iends and family, all of whom have helped in a variety of ways to
ensure the successful completion of this dissertation.

First, my thanks go to my advisor, Rita S. Gallin. Rita has provided consistent
support, encouragement and guidance throughout my graduate education. She listened to
me explore various research ideas only to eventually return to research on breast cancer
advocacy, which I started exploring in my very ﬁrst graduate course, which she taught,
on the political economy of women’s health.

I want to thank the members of my dissertation committee Linda Kalof, Aaron
McCright, and Sabrina McCormick. I greatly appreciated my collaborative research
projects with Linda during my graduate career that helped me develop my
methodological and analytical research skills. Aaron has provided support and
encouragement throughout my graduate career and has always been willing to listen to
my ideas and provide helpful, critical feedback on my work. Sabrina has always treated
me like a colleague and has collaborated with me on breast cancer advocacy research,
allowing me to develop as a researcher.

A special note of thanks goes to Maxine Baca Zinn. I was fortunate to have
Maxine as a professor and she was very inﬂuential in my understanding of feminist
theory. Although she was not on my dissertation committee, she has always been

supportive of my work.

During my time at MSU I have had the opportunity to get to know some
wonderful people who are now my closest ﬁiends. Rachael Shwom, Amy Fitzgerald,
Jessica Mills, Julie Hartman, Elisha Marr, Satoko Motohara, Gaby Saenz, Cathy Kuhn,
Karijn Nihoff, Natalie Bourdon, Maggie Corser and Linda Gjokaj have been incredible
sources of support, advice, and much needed laughter and perspective on life. I really
cannot imagine how I would have done this without their love, support and friendship.

Obviously, this study would not have been possible without the generous
contribution of the participants who gave their time to share with me their thoughts and
views. I thank them all. I also would like to thank my cousin in Puerto Rico, Sigrid Lopez
and her partner Marilyn, who opened up their home to me during my research trips as
well as the very kind family that housed me in Italy after only knowing me for a day.
They made my research an even richer and more enjoyable experience.

My dad, Gloria and Susie have been incredibly supportive throughout my
graduate career and I am so grateful for their constant love and support. My love and
gratitude also go to George and Opal. They have been in the thick of it through my ups
and downs in graduate school and dissertation writing, and have stuck with me through it
all. George has been an incredible source of love, strength, and encouragement. Opal has
been a consistent source of love and laughter.

Finally, I would like to acknowledge the generous ﬁnancial support that has made
this dissertation possible, including a Walker Hill International Scholarship, a MSU
Summer Retention Fellowship, and a MSU Graduate School Dissertation Completion

Fellowship.

vi

TABLE OF CONTENTS

LIST OF TABLES .................................................................................... x
LIST OF FIGURES ................................................................................. xi
KEY TO ABBREVIATIONS ..................................................................... xiv
CHAPTER 1
GLOBAL EXPANSION OF BIOMEDICAL BREAST CANCER ADVOCACY ......... 1
Research Objectives .............................................................................. 2
Putting Breast Cancer in a Global Context ................................................... 4
Breast Cancer as a “Contested Illness” ......................................................... 6
Types of Breast Cancer Advocacy ............................................................. 8
Development of Biomedical Breast Cancer Advocacy in the US ........................ 11
Global Expansion of Biomedical Breast Cancer Advocacy ............................... 15
Overview of Chapters .......................................................................... 18
CHAPTER 2
THEORETICAL PERSPECTIVES .............................................................. 23
Feminist Health Studies ....................................................................... 25
Health and Illness Theories ................................................................... 28
Social Construction of Health and Illness ................................................ 31
Biomedicalization ............................................................................ 32
Political Economy of Health and Illness .................................................. 37
Social Movement Theories ................................................................... 40
Health Social Movements .................................................................. 46
Transnational Social Movements, Networks and Coalitions ........................... 50
CHAPTER 3
THE RESEARCH PROCESS ..................................................................... 60
Research Design ................................................................................ 60
Conceptualization and Operationalization ................................................ 64
Deﬁnition of Terms .......................................................................... 66
Feminist Research Methodology ............................................................. 68
Situated Knowledges ........................................................................ 69
Selection of Organizations and Research Sites ............................................. 71
Entry into the Field ............................................................................. 75
Qualitative Research Methods ................................................................ 81
Data Collection and Analysis .................................................................. 84
Interviews ..................................................................................... 84
Qualitative Content Analysis ............................................................... 89
Participant Observation ..................................................................... 90
Chapter Summary .............................................................................. 92

vii

CHAPTER 4

ELITE ORGANIZATIONS AND GLOBAL EXPANSION ................................. 93
Organizational and Financial Resources ..................................................... 95
Susan G. Komen for the Cure ............................................................... 95
Avon Foundation ........................................................................... 104
Reasons for Global Expansion ............................................................... 108
Susan G. Komen for the Cure ............................................................. 109
Avon Foundation ........................................................................... 114
Conclusion ..................................................................................... 117
CHAPTER 5
THE SOCIAL CONSTRUCTION OF A GLOBAL BREAST CANCER CRISIS ...... 119
Breast Cancer as a Global Epidemic ....................................................... 122
Breast Cancer and Global Health Inequality ............................................. 127
Social Stigma, Myths and Misinforrnation in Developing Countries ............... 129
Breast Cancer as a Threat to Families ...................................................... 134
Conclusion: Biomedical Breast Cancer Advocacy as the Solution .................... 136
CHAPTER 6
THE CONSTRUCTION OF TRANSNATIONAL MIXED ACTOR COALITIONS...138
Susan G. Komen for the Cure: Developing a Transnational MAC ..................... 139
Partnering with Medical Professionals ................................................... 142
Partnering with the US Government ...................................................... 148
Partnering with Fred Hutchinson Cancer Research Center ........................... 156
Course for the Cure: Training International Breast Cancer Advocates .............. 159
Partnering with Corporations and Pharmaceutical Companies ....................... 161
Avon Foundation: Developing a Transnational MAC ................................... 166
Corporate Origins of International Advocates .......................................... 169
Participation of Medical Professionals ................................................... 171
Partnering with Novartis: Global Connection Ribbon Tour ........................... 172
Partnering with Local NGOs .............................................................. 174
Chapter Summary ............................................................................. 176
CHAPTER 7

THE GLOBAL EXPANSION OF PROCESSES OF BIOMEDICALIZATION VIA
BIOMEDICAL BREAST CANCER EVENTS, CAMPAIGNS AND PROGRAMS...178

Raising Awareness: The Importance of Early Detection ................................ 179
Advocacy Organizations as Disseminators of Medical Information ................... 185
Surveillance Medicine: Early Detection as Prevention .................................. 197

Survivorship as the Reward for Personal Vigilance .................................... 202
Creating At-Risk Identities .................................................................. 205
Conclusion ..................................................................................... 211

viii

CHAPTER 8
THE GLOBAL DIFFUSION OF CAUSE-RELATED MARKETING VIA

BIOMEDICAL BREAST CANCER ADVOCACY ORGANIZATIONS ................ 214
A Brief History of Cause-Related Marketing ............................................. 215
Global Expansion of Cause-Related Marketing .......................................... 218
Responses to Cause-Related Marketing as a New Form of Advocacy ................ 223
Global Proliferation of Breast Cancer Cause-Related Marketing ...................... 229
The Allocation of Funds ...................................................................... 233
Conclusion ..................................................................................... 237

CHAPTER 9

CONCLUSION .................................................................................... 240

Theoretical Implications ...................................................................... 240

Practical Implications ......................................................................... 243
APPENDIX

Interview Guide ................................................................................ 245
REFERENCES .................................................................................... 252

ix

LIST OF TABLES

Table 1.1: Types of Breast Cancer Advocacy in the US ........................................ 9
Table 3.1: Comparison of the US, Puerto Rico, and Italy in Relevant Categories ......... 74
Table 4.1: SGKC’s Board of Directors (2009) .................................................. 99
Table 4.2: SGKC’s Scientiﬁc Advisory Board Members (2009) ........................... 100
Table 4.3: SGKC’s Categorization of Corporate Sponsors and Partners .................. 102
Table 4.4: Avon Foundation’s Board of Directors (2009) .................................... 106
Table 4.5: Avon Foundation’s Breast Cancer Crusade

Scientiﬁc Advisory Board (2009) ............................................................... 107
Table 4.6: SGKC’s International Expansion Trajectory ...................................... 113
Table 4.7: Avon Foundation’s International Expansion Locations ......................... 115
Table 6.1: Founders, Partners, and Sponsors of the BHGI ................................... 158
Table 6.2: A Selection of Avon Foundation’s Partnering NGOs ........................... 175

Table 8.1: International Expansion of Fashion Targets Breast Cancer Cause-Related
Marketing Campaign .............................................................................. 231

Table 8.2: Avon Foundation’s and SGKC’s Allocation of Funds Internationally ........ 235

LIST OF FIGURES

Figure 1.1: The Shift towards Noncommunicable Diseases as Causes of Death ............ 4
Figure 1.2: Age-Standardized Incidence of Breast Cancer in Females according to

Geographic Regions (per 100,000) ................................................................. 6
Figure 2.1: Diagram of Theoretical Perspectives ............................................... 24
Figure 3.1: Conceptual Framework ............................................................... 61

Figure 3.2: Map of SGKC and Avon Foundation Office and Event Locations in Italy. . .76

Figure 3.3: Map of SGKC and Avon Foundation Ofﬁce and Event Locations in Puerto
Rico ................................................................................................... 80

Figure 3.4: Categories and number of participants involved in formal interviews. . . . . ....87

Figure 4.1: Laura Bush speaking to Komen Italia advocates on behalf of the US

government and SGKC ............................................................................. 98
Figure 4.2: KitchenAid’s Cause-Related Marketing Mixer .................................. 103
Figure 4.3: SGKC’s Allocation of Funds ...................................................... 104
Figure 4.4: New SGKC Name and Logo ....................................................... 110
Figure 5.1: Age-Standardized Incidence Rates of Breast Cancer, 2002 .................... 123
Figure 5.2: Age-Standardized Mortality Rates of Breast Cancer, 2002 .................... 124
Figure 6.1: SGKC’s Transnational Mixed Actor Coalition .................................. 141
Figure 6.2: US Breast Cancer Research Stamp and Italian Breast Cancer Stamp. . . . . ....l45

Figure 6.3: Announcement of the US-Middle East Partnership for Breast Cancer
Awareness and Research .......................................................................... 151

Figure 6.4: Age-Standardized Breast Cancer Rates for countries participating in the US-

Middle East Partnership for Breast Cancer Awareness and Research, World-Standard
(per 100,000) ....................................................................................... 153

xi

Figure 6.5: Age-Standardized Breast Cancer Rates for countries participating in the
Partnership for Breast Cancer Awareness and Research in the Americas, World-Standard

(per 100,000) ....................................................................................... 155
Figure 6.6: Johnson & Johnson Presence at SGKC’s Race for the Cure,

Bologna, Italy ....................................................................................... 163
Figure 6.7: New Balance’s Booth (left) and Advertisement for Pink Ribbon Running
Shoes (right) ........................................................................................ 165
Figure 6.8: Avon Foundation’s Transnational Mixed Actor Coalition ..................... 167
Figure 6.9: Event Participant being weighed by a Medical Staff Volunteer ............... 171
Figure 6.10: Avon Ecuador’s Global Connection Ribbon Tour Event ..................... 173
Figure 7.1: Marcha Por Una Causa: Cancer de Seno Event ................................ 184
Figure 7.2: Breast Self-Examination Cards in Spanish and English ........................ 188
Figure 7.3: Educational Material Distributed by Komen Puerto Rico ...................... 190
Figure 7.4: Excerpt from Avon Foundation’s Breast Health Resource Guide ............ 192
Figure 7.5: Cover Page of a Special Section dedicated to Breast Cancer .................. 196
Figure 7.6: Mobile Mammography Unit at Race for the Cure in Bologna, Italy ......... 200
Figure 7.7: F lyer for Ruta Pink in Puerto Rico ................................................ 201
Figure 7.8: Survivor Seating Area at the Closing Ceremony after the Race ............... 204
Figure 7.9: Breast Cancer Risk Information ................................................... 209
Figure 7.10: Excerpt ﬁ'om Avon Foundation’s Resource Guide in Puerto Rico .......... 210
Figure 8.1: Avon Breast Cancer Crusade Products ........................................... 219
Figure 8.2: Mazola Cause—Related Marketing Advertisement in Puerto Rico ............ 221

Figure 8.3: LILT and Estee Lauder Cause-Related Marketing Campaign in Italy ........ 225

Figure 8.4: Sosushi Cause-Marketing Campaign in Bologna, Italy ........................ 227

xii

ABCC

ACS

AF

BBCA

BCAM

BHGI

BSE

CFDA

DTCA

GBBCAO

FHCRC

FTBC

GCRT

GBCAS

IARC

IIE

INGO

LBCO

LILT

MAC

MEPI

NABCO

KEY TO ABBREVIATIONS
Avon Breast Cancer Crusade
American Cancer Society
Avon Foundation
Biomedical Breast Cancer Advocacy
Breast Cancer Awareness Month
Breast Health Global Initiative
Breast Self-Examination
Council of Fashion Designers of America
Direct-to-Consumer Advertising
Global Biomedical Breast Cancer Advocacy Organizations
Fred Hutchinson Cancer Research Center
Fashion Targets Breast Cancer
Global Connection Ribbon Tour
Global Breast Cancer Advocacy Summit
International Agency for Research on Cancer
Institute of International Education
International Non-Govemmental Organization
Local Breast Cancer Organization
Lega Italiana per la Lotta contro i tumori
Mixed Actor Coalition
Middle East Partnership Initiative

National Association of Breast Cancer Organizations

xiii

NBCC

NGO

NIH

POS

RF TC

SAC

SGKC

SLACOM

TAN

TSM

TSMO

UAE

US

WAWBC

WHO

National Breast Cancer Coalition
Non-Govemmental Organization

National Institutes of Health

Political Opportunity Structure

Race for the Cure

Sociedad Americana del Cancer

Susan G. Komen for the Cure

Sociedad Latinoamericana y del Caribe de Oncologia Medica
Transnational Advocacy Network
Transnational Social Movement
Transnational Social Movement Organization
United Arab Emirates

United States

Walk Around the World for Breast Cancer

World Health Organization

xiv

CHAPTER 1
GLOBAL EXPANSION OF BIOMEDICAL BREAST CANCER ADVOCACY

In the advanced global capitalist economy of the 21St century, market-based solutions to
social problems are increasingly becoming the norm. The global health system is no
exception. While highly proﬁtable medical endeavors such as genetic testing (Cowan
2008) and pharmaceutical development and rebranding (Peterson 2008) are thriving, the
most recent World Health Organization Report emphasized the dire need for a shift in
global health approaches toward primary healthcare, including universal healthcare
coverage reforms to increase health equity and public policy reforms to advance public
health interventions (WHO 2008, ix).

The fact that neoliberal governments and multinational pharmaceutical companies
promote an increasingly market-based approach to health and illness, moving further and
further away from promoting health equity and public health interventions may come as
no surprise.1 But, the potential role of transnational health social movements in the global
political economy of health and illness may be more unexpected because transnational
social movements have largely developed in resistance to globalizing neoliberal trends
(Evans 2005; Khagram et al. 2002; Tarrow 2005).

While deﬁnitions of social movements vary in terms of speciﬁcs, social
movements are generally understood as collectivities acting at least partially outside of
formal institutional channels, with some degree of organization and continuity, for the

purpose of “challenging or defending extant authority, whether it is institutionally or

 

' For my dissertation, 1 adopt Samantha King’s deﬁnition of neoliberalism as “a philosophy and a set of
economic and political policies aimed at cutting expenditures on public goods such as education, health
care, and income assistance in order to enhance corporate proﬁt rates.” (King 2006).

1

culturally based, in the group, organization, society, culture or world order of which they
are a part” (Snow et a1. 2004, l 1). Health social movements in particular have mobilized
to challenge medical policy, public health policy and politics, belief systems, medical
research and medical practices (Brown, 2005, 1). Within the context of globalization,
transnational social movements are primarily noted for the challenges they have posed to
neoliberal proliferation, environmental degradation, human rights’ violations, crimes
against women, war, and misguided development programs (Reitan 2007; Keck 1998;
della Porta 2005; Smith 2004). In most cases, therefore, transnational social movements
position themselves in opposition to global neoliberal policies. In the case of health,
however, it is possible that the priorities and activities of certain transnational health
advocacy organizations, particularly those with biomedical orientations, may actually

align with the neoliberal trend of market-based health solutions.

RESEARCH OBJECTIVES

The trend toward disease-speciﬁc biomedical health advocacy in the US2 is now
expanding globally. This form of advocacy, rather than addressing healthcare access and
equity on a national or international level, raises awareness about a particular illness,
placing it in competition with other illnesses for media attention, ﬁnancial resources, and
ultimately medical attention. As this form of advocacy expands beyond the US, members
of such groups are joining other actors in shaping the global political economy of health

and illness.

 

2 With the ﬁnancial success of biomedical breast cancer advocacy, other health advocates are embracing a
similar form of disease speciﬁc advocacy and adopting similar programs of awareness-raising events and
fundraising partnerships with corporate sponsors. Examples of this can be seen around such diseases as
ovarian cancer, testicular cancer, spinal muscular atrophy and heart disease.

2

The overarching theoretical goal of my dissertation research is to develop an
understanding of the role of transnational health advocacy organizations in the global
political economy of health and illness and transnational processes of biomedicalization.
To illuminate this issue, I use the case of the global expansion of biomedical breast
cancer advocacy organizations to address the following objectives.

(1) To understand how and why biomedical breast cancer advocacy organizations
are expanding beyond the US. To this end, the dissertation addresses how the decision to
expand and the choice of countries within which to expand were made by Susan G.
Komen for the Cure and the Avon Foundation. Speciﬁcally, were their decisions based
on the global distribution of breast cancer incidence or mortality rates? If not, what was it
based on? Also, how have these organizations expanded? What other actors, if any,
played a role in their expansion?

(2) To understand how forms of advocacy such as racing for the cure, cause-
related marketing and breast cancer awareness month and symbols, speciﬁcally the pink
ribbon, that are unique to biomedical breast cancer advocacy have been incorporated into,
and possibly adapted to, other political and cultural contexts.

(3) To understand the role that corporate sponsors/partners, including, but not
limited to, pharmaceutical companies, and medical professionals have played in the
global expansion of biomedical breast cancer advocacy organizations.

Addressing these objectives will contribute to our understanding of the potential role of
transnational health advocacy coalitions in the global political economy of health and

illness and transnational processes of biomedicalization.

PUTTING BREAST CANCER IN A GLOBAL CONTEXT

There has been a general shift in global health trends toward an increasing proportion of
noncommunicable diseases, like cancer and heart disease, which has become more
pronounced recently than heretofore. The World Health Organization predicts that by
2030, noncommunicable diseases will cause over three-quarters of deaths worldwide (see
Figure 1.1). In response to this trend, global health organizations are increasingly shifting
their attention from infectious diseases to noncommunicable diseases.

Figure 1.1. The Shiﬁ towards Noncommunicable Diseases as Causes of Death“
Deatrs(milions) URoad-traﬂ'rcaocldenb
Cerebrwasculardiseasa
I schaemlc heandismsw
I Camers

I Perinatal muses

I kute raprram interiors
I Diarrl'oeal dm

El Malaria

El HIV/AIDS

D Tibemriosis

 

 

2004200510620072018211192010 201120122013 20142015 2016 2018 2020 2022 2024 2026 2028 2030

“Selected causes.

 

 

 

Source: The World Health Report (WHO 2008)
Based on these trends, cancer and heart disease will become increasingly prominent

health concerns, not only in more industrialized countries, but in less industrialized

countries as well. Cancer, in particular, will be the cause of an increasing proportion of
deaths globally.

Given the general trend in deaths from noncommunicable diseases and the fact
that breast cancer is the second most common cancer in the world today and by far the
most common cancer in women (Parkin et a1. 2000, S17; Schwartzmann 2001), the
disease may appear to be a logical candidate for a priority on any women’s health agenda.
Nevertheless, while breast cancer is the most common cancer in women, heart disease is
the most common disease in women worldwide. Breast cancer is also the most common
cause of cancer mortality among women, accounting for 16 percent of cancer deaths in
women, even though heart disease remains the leading cause of women’s mortality
(Althuis et al. 2005 ; Parkin et al. 2000; Parkin 2006; Parkin et al. 2005).

While breast cancer incidence is increasing globally, the distribution of breast
cancer incidence is very uneven (see Figure 1.2). The majority of breast cancer cases
remain in more industrialized countries, even though rates are increasing in less
industrialized countries as well. Given the high incidence rate of breast cancer in
Northern America, it is not surprising that women with breast cancer in the US began
advocating over thirty years ago for increased funding, more research, and better
treatment to address the disease (Anglin 1997; Batt 1994). But, in other geographic
regions, breast cancer may not be a pressing health priority for women given its
prevalence in relation to both infectious and other noncommunicable diseases and in

many cases the need for basic access to primary healthcare (WHO 2008).3

 

3 Incidence refers to the number of new cases of breast cancer occurring in a given geographic location
during a speciﬁed amount of time, usually reported by year. Prevalence refers to the number of persons
who have been diagnosed with a breast cancer, and who are still alive in a given geographic location.

Figure. 1.2. Age-Standardized Incidence of Breast Cancer in Females according to
Geographic Regions (per 100,000)

Northern Anette
Amtrde/NewZeelend
Western Euope
Northern Euope
Sorthern Euope
5mm
Eastern Euope
Sorthern Africa
Western Asia
Cabbeen
Japan
Western Africa
Gertrdbmerica
Sodh-EeeternAsie
Northern Africa
Sodh Cenlrd Asra
Eastern Asia
Eedern Africa
Cline
Midde Alrica

0 20 40 60 80 11]]

 

 

 

 

 

Source: IARC, Globocan 2002

BREAST CANCER AS A “CONTESTED ILLNESS”

Given the prevalence of breast cancer, particularly in the US, it may seem intuitive that
advocacy developed around the disease, but it is important to interrogate the development
of breast cancer advocacy. While heart disease is the primary cause of death for women
worldwide, only recently have heart disease awareness campaigns, similar to those for
breast cancer, emerged in the US. Additionally, diseases like diabetes, which may be less
fatal, but are more prevalent, and affect quality of life, have also lacked the type of
advocacy that has developed around breast cancer. It is therefore necessary to understand
why breast cancer became a contentious disease, one that spurred so much advocacy and

attention, in the US.

 

Mortality is the number of deaths occurring due to breast cancer in a given geographic location during a
speciﬁed amount of time, usually reported by year (IARC Globocan 2002).

6

According to Brown and his colleagues (2004, 52-53), “contested illnesses” are
conditions that are either unexplained by current medical knowledge or have purported
environmental explanations that are often disputed by medical professionals and
scientists. People concerned with these illnesses may collectively organize to achieve
medical recognition, treatment, and/or increased medical research. In some cases, where
environmental factors are suspected, advocacy groups may strive to shift attention away
from strictly medical explanations of the disease and call for research into environmental
causes and prevention of the illness (Brody 2003; Brody et al. 2005; Brown et al. 2006;
Eisenstein 2001; Krimsky 2000;McCormick et al. 2004; Steingraber 2000).

Breast cancer is a contested illness due to the lack of a deﬁnitive explanation of
its etiology. Despite the discovery of the BRCA—l and BRCA-2 gene mutations, genetic
predispositions account for up to only ten percent of all breast cancer cases (Klawiter
2002; Wade 2007). Additionally, these genetic mutations are not particularly prevalent in
the population and cannot explain the international or interethnic variation in breast
cancer risk. Medical professionals tend to explain the increasing rates of breast cancer,
particularly among women in industrialized countries, by citing changing reproductive
behaviors (Aronowitz 2007). Delayed childbearing or lack of childbearing, birthing fewer
children, not breastfeeding (or breastfeeding for only a short period of time), and using
hormone replacement therapy all increase a woman’s lifetime exposure to estrogen,
which is associated with increased breast cancer risk (Aronowitz 2007). Thus, in contrast
to a disease like lung cancer, where a clear link has been drawn between smoking and
lung cancer risk and only a limited number of cases remain unexplained, breast cancer

remains an elusive disease despite much medical research.

Finding medical explanations of the disease unsatisfactory, many breast cancer
patients in the US became frustrated and joined together in search of answers regarding
breast cancer, with the ultimate goal of eradicating the disease. But despite sharing the
same goal of eradicating breast cancer, breast cancer advocacy has not been a monolithic
phenomenon. Rather, distinct forms of breast cancer advocacy have developed within the

US.

TYPES OF BREAST CANCER ADVOCACY

Breast cancer advocacy, as it has developed in the US, can be divided into three distinct,
though not entirely mutually exclusive, categories. In her extensive case study of breast
cancer advocacy in the San Francisco Bay Area, Klawiter (2008) developed a typology of
three distinct forms of actions taken to confront the disease, which I have adapted for the
purposes of this chapter (see Table 1.1). While her research focused on dynamics within a
particular geographic area, this typology is applicable to the broader US, which has seen
all of these forms of breast cancer advocacy over the past twenty to thirty years.
Biomedical screening and early detection advocacy is the most prominent form of
breast cancer advocacy in the US. Biomedical breast cancer advocates focus on the
problem of lack of awareness of and access to screening for breast cancer. Given the
biomedical focus of this type of advocacy, biomedical breast cancer advocates have a
positive view of the medical establishment, seeing them as allies in the quest to conquer
breast cancer. These organizations had elite and often professional origins, frequently
being initiated by corporations (e.g., Avon, Estee Lauder) and celebrity or wealthy
families who formed organizations after losing a member of their family to breast cancer.

Drawing on the rhetoric of the 19703 women’s health movement, these organizations in

practice often function more as philanthropic charities, but have self-identiﬁed as social

movements.

Table 1.1. Types of Breast Cancer Advocacy in the US

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Biomedical Patient Environmental/
Screening and Empowerment/Feminist Cancer Prevention
Early Detection Treatment
Deﬁnition of the Lack of awareness Entrenched, male- Proﬁt-driven global
Problem of and access to dominated cancer cancer industry
screening establishment committed
to “business-as-usual”
Public Culture Race for the Cure Women and Cancer Toxic Tour
Walk
Privileged Breast cancer Women living with Victimized
Identity survivors cancer communities
Representative Pink ribbon “Cancer sucks” pins Skull and
Symbol crossbones
Emotion Culture Hopeful, grateful, Public anger but private Unmitigated anger
upbeat, positive, compassion and support targeted at the
celebratory for women with cancer cancer industry
Attitude toward Trusting, Critical, unintimidated, Critical; strategic
Science respectful, participatory use of science
committed
Ideological and Philanthropic Feminism; 19703 Environmental
Organizational organizations; women’s health justice movements;
Origins" 19703 women’s movement, lesbian feminism
health movement communities, AIDS
activism
Organizational Advocacy Activist Activist
Identity*
Organizational Hierarchical; Local organizations; Local organizations;
Form" national network; participation in national participation in
global network network (National Breast national network
Cancer Coalition) (NBCC); some
international
networking with
Canadian afﬁliates
Organizational Elite; professional Grassroots Grassroots
Origins"

 

 

Table 1.1 (Continued)

 

Corporate Unproblematic Limited use of Limited use of
Sponsorship“ widespread use of corporate sponsorship corporate
corporate sponsorship with companies sponsorship with
whose products companies

complement the goal whose products
of eradicating breast complement the
cancer goal of
eradicating
breast cancer

 

 

 

 

 

 

Source: Adapted from Klawiter (2008, 47)
*Categories that I added to the typology based on interviews, participant observation, and documentary
analysis

In stark contrast to biomedical breast cancer advocacy, patient empowerment and
feminist treatment activists often have grassroots origins, developing out of communities
of women who are dealing with breast cancer. These activists focus on the problem of the
male—dominated cancer establishment and advance participatory approaches to scientiﬁc
research whereby people with the disease in question would play a role in deﬁning the
research priorities. In addition to drawing on the 1970’s women’s health movement, these
activists also have a distinctly feminist orientation. Rather than working toward gaining
greater access to biomedical screening and treatment in its current state, they advocate a
new inclusive scientiﬁc paradigm.

Finally, similar to patient empowerment and feminist treatment advocacy,
environmental and cancer prevention advocacy takes a critical stance toward science and
medical professionals. These activists focus their attention on the proﬁt-driven global
cancer industry. With grassroots origins, these activist organizations often develop in
communities where cancer clusters appear to exist. They often strategically partner with
scientists to investigate the increased cancer incidence rates in their communities. In
addition to drawing on feminism, these organizations have strong connections to

environmental health and justice movements.

10

 

While all three types of breast cancer advocacy organizations remain active in the
US today, biomedical breast cancer advocacy is the form that is expanding globally.
Therefore, in what follows, I will provide a more detailed account of its development in
the US and then discuss the recent global expansion of biomedical breast cancer

advocacy organizations.

DEVELOPMENT OF BIOMEDICAL BREAST CANCER ADVOCACY IN
THE US

In the 19703 in the US, the public announcements of personal experiences with breast
cancer by several famous women such as Betty Ford and Happy Rockefeller (Batt 1994,
269; Lerner 2003) paved the way for breast cancer activism. Babette Rosmond, for
example, wrote about her experience, thereby contributing to changes in informed
consent laws 30 that surgeons have to discuss treatment options with breast cancer
patients prior to performing a mastectomy (Lerner 2003). Personal testimonies and
reports have continued from the late 19703 until today (Rosenbaum 2000; Batt 1994).
Initially shocking, and then widely read, these testimonies have had a major impact on
the public, bringing breast cancer more fully onto the social landscape.

In the 19803, making the public aware of the most frequent killer of middle-aged
women was a difﬁcult and distant goal. Nevertheless, during the 19803 breast cancer
support groups began to form across the US. These support groups provided a
transitional space for women with breast cancer to transform their personal experience
with the disease into a politicized view of the illness (Altman 1996; Brenner 2000).
Groups supplying information and assistance to women with breast cancer proliferated.
Women with breast cancer began to see themselves as part of a community, a sisterhood

(Brenner 2000). Drawing on the women’s health movement of the 19703, these women

11

attacked the sexism of the health research system in the US (Altman 1996; Anglin 1997;
Brenner 2000; McCormick 2003; McCormick 2003). They worked to transform breast
cancer into a mainstream area of research.

Prior to the emergence of grassroots breast cancer advocacy in the US, the
American Cancer Society sponsored programs for women with breast cancer such as
“Reach for Recovery” and “Look Good, Feel Good,” that provided breast cancer patients
with limited, one-on-one support from women who previously had breast cancer (Love
1997). The programs were primarily focused on returning women to a feminine beauty
standard (thereby making them “feel good”) by encouraging them to wear temporary
breast prostheses and put on make-up everyday. This disguising of breast cancer was
partially in response to the social stigmatization of the disease that resulted from strong
cultural perceptions of the breast as related to vitality, sexuality and motherhood (via the
act of breastfeeding) (Olson 2005). Thus, breast cancer was not just a threat to a
woman’s health but also a threat to her femininity.

Due to the work of breast cancer activists in countering the stigma, billboards,
advertisements, radio and television programs, and books openly discuss most aspects of
the disease today. Breast cancer advocates use these fora to encourage women to perform
monthly breast self-exams and start getting yearly mammograms once they reach 40
years of age. By speaking out about breast cancer publicly, breast cancer activists
reduced the stigma and shame surrounding the disease in the US (Anglin 1997;
Casamayou 2001; McCormick et al. 2003).

The pink ribbon became the culturally ubiquitous symbol of breast cancer

throughout the US in the 19903 (Fernandez 2005; Moffett 2003; King 2006). Developed

12

in 1992 by Evelyn Lauder, a breast cancer survivor and Senior Corporate Vice-President
of Estée Lauder, in conjunction with Self Magazine, it is currently being promoted by
biomedical breast cancer advocates globally. Pink ribbons serve as reminders for women
to tend to their health as well as symbols of public support for ﬁnding a cure for breast
cancer. The pink ribbon campaign has successfully created a deeper sense of public
concern and awareness about breast cancer.

Biomedical breast cancer advocacy has also advanced unique forms of advocacy.
Instead of more conventional forms of social movement activity such as protests,
boycotts, and marches, breast cancer advocacy organizations have developed practices
such as racing and shopping for the cure that are geared toward raising awareness and
funding breast cancer research. “Race for the Cure,” through partnerships and
sponsorships, and “Shop for the Cure” promotions and products are largely tied to
corporations. In the US, “Race for the Cure” events taking place throughout the country
have been sponsored by companies such as Ford, Yoplait, Avon, American Airlines,
BMW, and Kellogg, along with pharmaceutical companies such as AstraZeneca and
Johnson & Johnson. Shopping for the cure has taken place through various corporate
promotions such as Yoplait’s “Save Lids, Save Lives,” BMW’s “Test Drive for the
Cure,” KitchenAid’s “Cook for the Cure,” and Republic of Tea’s “Sip for the Cure,” that
donate percentages of their sales to breast cancer organizations. These forms of advocacy,
as well as ties to corporations, and particularly to pharmaceutical companies, are
expanding beyond the US as the biomedical breast cancer movement redeﬁnes its

mission as the “global eradication of breast cancer” (Komen website 2008).

13

A series of powerful, professionalized breast cancer organizations and
foundations emerged from this movement. One of the largest breast cancer foundations,
the Susan G. Komen Foundation, was established in 1982 by Nancy Brinker when her
sister died of the disease (Klawiter 2000; Casamayou 2001). In 1984, National Breast
Cancer Awareness Month was established by AstraZeneca, Cancer Care, Inc. and a group
of oncologists (Brenner 2000; Zones 2000; King 2006). The following year Amy
Langer’s National Alliance of Breast Cancer Organization (NABCO) in New York
became one of the ﬁrst national organizations to provide information and support to
women across the US (Brenner 2000; King 2006).

The National Breast Cancer Coalition (NBCC) was founded in 1991 (Brenner
2000; Weisman 2000; Casamayou 2001). At that time, other organizations were working
deterrninedly to get women mammograms, access to services, and more humane
treatment. None had yet attempted to shape research or policies. NBCC activists’ efforts
were groundbreaking, gaining the group’s advocates participation in government health
research proposals and opening up funding mechanisms for breast cancer. The founders
conceived of the organization as a new kind of breast cancer organization meant to
inﬂuence politics and gain more funds for research (Stabiner 1997). The ﬁrst concern of
many breast cancer advocates was the small amount of funding devoted to the disease.4
These advocates pushed for more money and for inﬂuence regarding how it would be
spent. In 1993, the work of NBCC and other advocates led to the passage of the ﬁrst
governmental plan for breast cancer, the National Action Plan on Breast Cancer

(W eisman 2000; Brenner 2000; Steingraber 2000; Casamayou 2001). Due to the work of

 

‘ See Klawiter (2008, 6-7) for ﬁgures on the National Health lnstitute’s and National Cancer Institute’s
allocation of funds for research on various cancers and other diseases. Klawiter (2008) argues that, in fact,
breast cancer was not ﬁnancially marginalized by these government institutions.

14

advocates who urged legislators to support new research, the US government established
the Breast Cancer Research Program, housed in the Department of Defense, in order to
provide federal funding speciﬁcally on research about breast cancer prevention,
detection, diagnosis, and treatment (Brenner 2000; Rosser 2000; Weisman 2000; King,
2006).5 As of ﬁscal year 2009, over two billion dollars have been appropriated for this
program (Department of Defense 2008; NBCC 2009).

Further, by 2008, breast cancer organizations spanned the US, and research was
increasingly well-funded by the US government. In 2005, NBCC encompassed more
than 500 groups across the US. These organizations have major political inﬂuence and
have exercised their sway in the legislative arena (Weisman 2000). Advocates from the
organization sit on the President’s Cancer Panel and the National Cancer Policy Board,
among other panels, and they testify in front of the House, the Senate, the President’s
Cancer Panel and other governmental agencies. As biomedical breast cancer advocacy
organizations gained legitimacy and success in the US, some organizations have begun to
set their sights on expanding to other countries.

GLOBAL EXPANSION OF BIOMEDICAL BREAST CANCER
ADVOCACY

Increasingly, biomedical breast cancer advocacy is being promoted globally by Susan G.
Komen for the Cure (SGKC), the Avon Foundation, the Breast Health Global Initiative,
pharmaceutical companies (e.g., Johnson & Johnson and AstraZeneca) and other
corporations through “cause-related marketing” and sponsorship of advocacy events.6

The Breast Health Global Initiative (BHGI) is an initiative founded by the Fred

 

5 The budget was housed in the Department of Defense in order to safeguard it ﬁ'om potential budget cuts.
6 “Cause-related marketing” refers to a mutually-beneﬁcial partnership between a for-proﬁt business and a
non-proﬁt organization in which the for-proﬁt business ﬁnancially supports the non-proﬁt organization by
donating a portion of its proceeds from the sale of a cause-related product (King 2006).

15

Hutchinson Cancer Research Center (FHCRC) and SGKC to “develop, implement and
study evidence-based, economically feasible, and culturally appropriate ‘Guidelines for
International Breast Health and Cancer Control’ for underdeveloped nations to improve
breast health outcomes” (BHGI 2008). These actors are promoting a biomedical model of
breast cancer advocacy that focuses on raising awareness about breast cancer, promoting
breast self-exams, clinical exams and mammography, and raising funds to support
medical research geared toward improved treatment options, pharmaceutical
interventions, and ultimately ﬁnding a cure. Environmental causes, prevention, and
feminist critiques of the political economy of breast cancer are largely absent from this
globally expanding form of advocacy.

The literature on the global aspects of breast cancer advocacy is very limited.
Klawiter (2000) addressed breast cancer advocacy on a global scale in her analysis of
diverse strands of breast cancer activism. She argues that while the First World
Conference on Breast Cancer in Kingston, Canada in 1997 was indeed a “worldwide”
conference in terms of delegates who were present, it was made possible by grassroots
activism in North America and framed in terms of North American women’s experience
and history with breast cancer. In her analysis of breast cancer advocacy, King (2006, 81)
times the expansion of US-based breast cancer advocacy, primarily through the Avon
Foundation and SGKC, a3 “imperial charity” in which, after successfully capturing the
US market, these philanthropic foundations seek market expansion through neoliberal
projects in the guise of advocacy for women’s health. In particular, she argues that US
breast cancer advocacy organizations do not expand internationally independent of long-

standing corporate backers, such as AstraZeneca. Therefore, the goal of the expansion of

16

these advocacy organizations is not merely to advance some form of social good, but also
to initiate “techniques for market penetration and retention” (King 2006, 84).

While scholars are beginning to address the global expansion of biomedical breast
cancer advocacy, it is largely un-theorized. Why have biomedical breast cancer advocacy
organizations expanded globally? How have decisions been made regarding which
countries to expand to? How have advocacy activities, symbols and structures been
incorporated into, and possibly adapted to, other political and cultural contexts? These
questions remain largely unanswered by the current literature. King (2006, 145), who has
provided the most in-depth analysis of the global expansion of breast cancer advocacy,
notes that her analysis is “necessarily speculative” given that her data are exclusively
drawn from Avon Foundation literature. Therefore, the global aspects of biomedical
breast cancer advocacy require further attention.

Furthermore, while the literature largely refers to the “breast cancer movement,”
“advocates,” and “activists,” it fails to engage with social movement literature as a whole
and, more speciﬁcally, with literature on transnational social movements and health
social movements. Examining the global expansion of breast cancer advocacy in light of
social movement theories has the potential to provide a deeper understanding of this
particular situation, as well as make useﬁtl contributions to the deﬁnition of social
movements, understanding of transnational social movement processes, global health
social movements, and social movements as globalizing forces. My research focuses on
the role of transnational biomedical breast cancer advocacy organizations in order to
better understand the role that these un-exarnined organizations play in the global

political economy of health and illness and processes of biomedicalization.

17

OVERVIEW OF CHAPTERS

Drawing principally on health and illness and social movement theories, in Chapter 2 I
provide an explanation of my chosen theoretical framework. 1 utilize a diagram to
visually represent the theoretical perspectives informing my research. My theoretical
orientation draws on the broad area of feminist health studies that has provided critical
appraisals of global processes of biomedicalization as well as the capitalist political
economy of health and illness, particularly as they relate to diseases affecting women. To
answer my research questions, I utilize theories from the sociology of health and illness
and have attempted to integrate the political economy of health and illness, the social
construction of illness, and processes of biomedicalization, which are often presented as
distinct theoretical pursuits in the existing literature. Within the realm of social
movement theory, I primarily draw on health social movement and transnational social
movement theories, also attempting to integrate them into an examination of transnational
health advocacy organizations, an effort previously lacking in the literature. Finally, I
also explore the overlap between social movements and health and illness, by integrating
transnational health advocacy organizations into understandings of the political economy
of health and illness, the social construction of illness, and processes of
biomedicalization.

In Chapter 3, I discuss the methodology and methods used in this study. The study
utilizes an intrinsic case study approach, with my research centering on globally
expanding biomedical breast cancer advocacy organizations. The purpose of this
approach is to understand how and why biomedical breast cancer advocacy organizations
are expanding globally. The global expansion of biomedical breast cancer advocacy

provides a unique and interesting case in which (1) US-based biomedical breast cancer

18

advocacy organizations are expanding to other countries, (2) transnational health
advocacy coalitions may be playing a signiﬁcant role in the global political economy of
health and illness and processes of biomedicalization, and (3) theoretical
conceptualizations of health social movements and transnational social movements are
challenged.

After presenting the rationale for an intrinsic case study approach, I discuss
feminist research methodology as it relates to my dissertation. I then address the selection
of the organizations that I focus on in my dissertation as well as the selection of the
research sites. Finally, I discuss the qualitative research methods that I employed for this
study, focusing on the particular role that each method played in addressing my research
objectives.

In Chapter 4, I present my ﬁndings regarding the reasons for Susan G. Komen for
the Cure’s and the Avon Foundation’s global expansion as well as the trajectory of each
organization’s global expansion. SGKC and the Avon Foundation, despite their
differences, both “went global” to expand their brand to new markets. For both
organizations, global expansion was the logical extension of a general pattern of
organizational growth. Both organizations globally expanded based on a corporate model
of market expansion.

While I address the reasons for the organizations’ expansion in Chapter 4, in
Chapter 5 I present the ways in which SGKC and the Avon Foundation socially
constructed breast cancer on a global scale in order to legitimize their expansion. Susan
G. Komen for the Cure and the Avon Foundation have purportedly expanded globally in

order to confront the global epidemic of breast cancer. In Chapter 5, I challenge the claim

19

that breast cancer is a global health crisis in need of a global biomedical breast cancer
movement. I do this by examining how biomedical breast cancer advocates have actively
constructed breast cancer as a global epidemic and crisis in light of actual global breast
cancer incidence and mortality rates. Additionally, I argue that advocates from both
organizations frame the global breast cancer problem as being caused by lack of
awareness of and education about breast cancer leading to low levels of early detection,
thereby positioning their biomedical brand of advocacy as the appropriate solution to the
problem.

In Chapter 6, I describe how SGKC and the Avon Foundation are expanding
internationally. The ﬁndings that I present in this section indicate that biomedical breast
cancer advocacy organizations have formed transnational mixed actor coalitions (MACS),
in which they are the central organizations, but other non-state actors, such as local
NGOs, as well as government agencies, medical professionals, medical research centers,
and corporations are also included. While Khagram and his colleagues (2002, 11), like
many other social movement scholars, argue that the non-govemmental sector, and
speciﬁcally, social movements, represent a distinct sector of society, I found that in their
effort to globally expand, biomedical breast cancer advocacy organizations are intricately
tied to governmental, medical, and corporate sectors in ways that blur the boundaries
between their identities, thereby blurring the boundaries between the various social
sectors.

In Chapters 4, 5 and 6, therefore, I provide a broad picture of the SGKC’s and
Avon Foundation’s global expansion. In Chapter 7, I draw on my ﬁndings regarding how

forms of biomedical breast cancer advocacy have been incorporated into, and adapted to,

20

other political and cultural contexts to argue that the diffusion of biomedical breast
cancer advocacy activities are furthering processes of biomedicalization globally. With
only minor cultural and political adaptations, SGKC and Avon Foundation events,
campaigns and programs in other countries are strikingly similar to their events in the
US. By raising awareness about early detection, disseminating medical information,
promoting “surveillance medicine”, and creating new risky subjects and biomedical
breast cancer advocate identities among women across the globe, biomedical breast
cancer advocacy organizations are playing a signiﬁcant role in establishing a biomedical
understanding of breast cancer outside of the US. The foci of SGKC and Avon
Foundation events, campaigns, and programs are twofold: raising awareness and raising
funds. Chapter 7 addresses the former of these two.

In Chapter 8, I move on to examine the role of fundraising in the global expansion
of biomedical breast cancer advocacy organizations in the context of the global political
economy of health and illness. I argue that through their collaboration with corporations
and speciﬁcally pharmaceutical and medical technology and equipment companies,
biomedical breast cancer advocacy organizations are creating economic opportunities for
corporate market-expansion, particularly in health-related ﬁelds. Additionally, with
regard to cause-marketing, biomedical breast cancer advocacy organizations are
introducing this form of corporate/advocate hybridization in political and cultural
contexts where it previously did not exist.

In the ﬁnal chapter, I propose theoretical and practical implications based on my
research. I ﬁrst present the challenges posed by globally expanding biomedical breast

cancer advocacy to the existing deﬁnitions of social movements, and transnational social

21

movements in particular. I then elaborate on the role of globally expanding biomedical
breast cancer advocacy in processes of biomedicalization and the global political
economy of health and illness. Finally, I discuss SGKC’s and Avon Foundation’s
corporatized and individualized approach to health problems with regard to the future of

health advocacy.

22

CHAPTER 2
THEORETICAL PERSPECTIVES

My research questions arose out of my feminist health theoretical orientation, which has
informed my critical approach to the capitalist political economic context of health and
illness and accelerating processes of biomedicalization. Additionally, my research
questions developed out of my engagement with social movement theory, which
informed my approach to the role of agents of “change” in effecting issues of health and
illness. Within this broad oeuvre, I draw on strands from the sociology of health and
illness literature and social movement theory. Within these broad theoretical ﬁelds, I
utilize insights from the literature on social construction, political economy,
biomedicalization, health social movements and transnational social movements.

In Figure 2.1, I provide a visual representation of the theoretical perspectives that
inform my research. Feminist health perspectives contributed to the formation of my
overarching research question regarding the political economy of health and illness and
processes of biomedicalization. I depict feminist health perspectives as the encompassing
circle in my diagram because these perspectives informed the overall project. In
answering my research questions, I draw from two bodies of literature: health and illness
theories and social movement theories. These areas are theoretically distinct; however, I
present them as overlapping because I am interested in the intersection between the two
areas where social movements engage with issues of health and illness. Within the
expansive ﬁeld of health and illness, I focus on the social construction of health and

illness, processes of biomedicalization, and the political economy of health and illness.

23

Iii-gun 2.1. Diagram of Theoretical Perspectives

 
    

Feminist Health
Studies

 
 
   
 

  
 

Health and
Illness Theories

    

Social
Movement
Theories

   
    
   
   

Health
Social
Movements

 
 
 
  

 
  

Bio-
medicalization

  

 

 

 

While these areas are often theorized separately, 1 am interested in the
interconnections among them, which is why they are presented as overlapping. Among
theories of social movements, 1 am particularly interested in health social movements,
transnational social movements, and more speciﬁcally, their intersection in transnational
health social movements. By drawing on these theories, I seek to illuminate the ways in
which transnational health social movements, speciﬁcally transnational biomedical breast
cancer advocacy organizations, contribute to the social construction of health and illness,
processes of biomedicalization, and the political economy of health and illness on a

global scale.

24

FEMINIST HEALTH STUDIES

My research questions were prompted by my feminist health theoretical orientation.
Feminist health scholars have critiqued the biomedical model of women’s health as being
removed from the social, political, and economic realities of women’s lives that affect
their health and well-being (Ruzek et al. 1999; Ruzek 1999). This critique is not an
attempt to completely abandon biomedical perspectives of women’s health. On the
contrary, feminists have also made signiﬁcant contributions to biomedicine. According to
Ruzek et al. (1999, 13), feminist perspectives “have spurred recognition of how gender
affects etiology, natural history, and treatment of disease.” Nevertheless, the biomedical
model of health and illness fails to interrogate the underlying dynamics of what actually
“produces health for different groups of women” (Ruzek et al. 1999, 13). Feminist health
scholars argue for a model of health that is more inclusive. This requires recognizing and
dealing with complexities and differences in women’s lives. Multiple factors produce
health or, conversely, contribute to disease and illness for women. These social,
economic, political, occupational, educational, and environmental factors must be central
in the quest to improve women’s health.

In addition to critiquing a strictly biomedical model of health, a number of
feminist health scholars also have scrutinized processes of biomedicalization that are
spreading globally through the medical industrial complex. Feminist health scholars
argue that processes of biomedicalization, in concert with companies that produce various
health—related commodities, are promoting the Western biomedical worldview. “Part of
the new biomedicalization includes what is now being termed ‘surveillance medicine,’
the creation of potentially diseased persons through risk analyses of individuals,

communities, and populations” (Clarke et al. 2005, 22). Globalizing processes of

25

biomedicalization encompass the shift toward “surveillance medicine,” which dissolves
previous categories of “healthy” and “ill” persons in favor of new categories of “at-risk—
individuals, communities, and populations, using strategies of pathologization and
vigilance” (Clarke et al. 2005, 22). As argued by Clarke and Oleson (1999, 14), “new
processes of biomedicalization extend science, technology, and medicine further into our
lives. Surveillance medicine is creating a new culture of risk and new burdens of health
care consumption that particularly implicate women” (Clarke and Oleson 1999, 14).
Being “at risk” is now being transformed into “requiring biomedical
prevention/intervention” (Clarke et al. 2005, 22). Feminist health scholars question to
what extent these globalizing processes of biomedicalization actually improve women’s
health on a worldwide scale, versus simply increasing proﬁt by the proliferation of
medical technologies, treatments, and pharmaceuticals.

In addition to critiquing the global expansion of processes of biomedicalization,
feminist health scholars have also examined the current advanced capitalist political
economy, in which health and healthcare are commodities, rather than basic human rights
for all people. They are critical of the inherent inequality within this system, in which
people who can afford it are granted the “Cadillac” of medical care and preventative and
elective medical treatments, while others struggle to survive, lacking the most basic of
healthcare services (Clarke 2005). The concept of a “biomedical industrial complex” has
been adopted by Clarke and Oleson (1999, 20) to describe the current political economic
structure of capitalist health systems. Originally put forth by Relman and colleagues
(1987, as cited in Clarke and Oleson 1999, 20), the concept of a “biomedical industrial

complex,”

26

denote[s] a parallel politico-economic institutional sector to the military industrial
complex (and not unrelated to it). Moreover, this medical industrial complex is
globalizing. By and large, the Western biomedical worldview is exported along
with companies which can produce many commodities—many of them
technoscientiﬁc—which are requisite for proper health care within this
worldview.
Feminist health scholars are critical of processes of biomedicalization and the economic
interests that are increasingly deﬁning the political economy of health and illness within a
narrow biomedical model on a global scale. Nevertheless, empirical investigations of
how processes of biomedicalization are globalizing, and speciﬁcally, what role advocacy
organizations that are comprised of mostly women and are theoretically acting in the
interest of women’s health, such as biomedical breast cancer advocacy organizations,
may play in these processes are sparse.

Finally, like other feminist health scholars, and feminists more generally, I am
committed to social movements and political solutions that are aimed toward improving
the health and well-being of all women, not just a select few. As aptly stated by Clarke
and Oleson (1999, 15),

How can we analyze the breast cancer activism of very elite women and

physician’s wives that made that disease the “cause” of the year 1996 for

corporate as well as individual charity, sending the ﬁinds raised to a biomedicine
that refuses to address cause and prevention?
Through my research, I seek to address some of the large issues that feminist health
scholars are currently grappling with related to processes of biomedicalization, the
political economy of health and illness, and the globalizing of biomedical models of
advocacy, that are purportedly acting in the interests of all women’s health, but may

actually steer global health agendas, ﬁnancial resources, and medical attention to the

beneﬁt of a minority of women, at the expense of broader health reform.

27

Health and Illness Theories
The sociology of health and illness has made signiﬁcant contributions to our

understanding of the critical role that social factors play in determining the health of
individuals, social groups, and entire societies (Cockerham 2004). While the World
Health Organization deﬁnes health as “a state of complete physical, mental and social
well-being and not merely the absence of disease or inﬁrmity”, sociologists have found
that medical, lay, economic, and environmental perspectives of health vary from this
deﬁnition (Cockerham 2004;WHO 2009). Additionally, sociologists of health and illness
differentiate between disease, a biophysiological state, and illness, a social state in which
particular meaning is assigned to a physical or mental state (Conrad 2005). In attempting
to better understand the maintenance of health and the production of disease and illness,
sociologists have explored these topics through social psychological, inequality,
institutional, and environmental perspectives, which I brieﬂy outline before turning to the
areas within the sociology of health and illness that I use to explain my ﬁndings.

Drawing on social psychology, sociologists of health and illness have explored
the ways in which social interactions affect understandings and experiences of health and
illness. In particular, sociologists have used a social psychological approach to
understand the dynamics of doctor-patient relationships as well as the dynamic between
doctors and other healthcare workers (e.g., nurses, physician assistants) (Cockerham
2004). Sociologists have found that the social interaction between various groups is
shaped by race, class, and gender power dynamics, although there is an increasing trend
toward mutual participation in these interactions, in which all parties involved are heard
in what becomes a process of negotiation regarding medical treatment (Cockerham

2004)

28

In addition to drawing on social psychological perspectives, sociologists of health
and illness have drawn attention to the ways in which social inequalities with regard to
race, class and gender have largely shaped the social distribution of disease and illness.
While the biomedical perspective, the predominant lens through which people understand
health and illness, emphasizes health and disease in individuals, sociologists have found
social inequalities to be signiﬁcant predictors of health and disease in both industrialized
and developing countries (Brown 2000). By examining the impacts of poverty, income
inequality, racial and gender inequality, sociologists of health and illness have
demonstrated the need for political, social and economic efforts to promote health and
reduce the occurrence of disease (Brown 2000). This perspective challenges the notion
that biomedical interventions are solely responsible for health and illness outcomes.

Institutional perspectives within the sociology of health and illness primarily
focus on the medical profession, hospital organization, and healthcare systems. From this
perspective, sociologists of health and illness have studied the rise of medical power
through the professionalization and consolidation of medical knowledge and expertise,
largely through the establishment of the American Medical Association (Annandale
2002; Conrad 2005) as well as the current decline of medical professional’s power in
light of the rise of government regulation, managed care, and corporations in the health
care business (Conrad 2005). Additionally, institutional perspectives on health and illness
have documented the development of hospitals as a social institution as well as the
changing organization of hospitals over time. Finally, from this perspective, sociologists
of health and illness have explored health care delivery systems in the US as well as

globally (Conrad 2005).

29

Finally, sociologists of health and illness and environmental sociologists have
joined together in addressing issues of health, illness and the environment as integrated
phenomena. The ﬁeld of environmental health that has developed through the
collaboration of environmental and medical sociologists has posed signiﬁcant challenges
to the biomedical paradigm. Environmental health perspectives provide a broader,
contextualized deﬁnition of health and illness. According to Brown (2002, 7), the
broadest deﬁnition of environmental health

would include the totality of unhealthy living and working conditions: bacteria

and viruses in human waste; animal vectors for infectious diseases; surface water

and groundwater pollution; air pollution from ﬁres, vehicle exhaust, and
incineration; chemical and petroleum product spills and explosions; and disasters,
such as ﬂoods, hurricanes, and ﬁres (which may be either natural, human caused,
or human exacerbated).
Because this deﬁnition is particularly broad and all-encompassing, Brown (2002, 7)
suggests that environmental health researchers, activists, and policy makers have rightly
focused on “the health effects caused by toxic substances in people’s immediate or
proximate surroundings (soil, air, water, food, and household goods)” Even with a
narrower focus on health effects caused by chemical-related, air-pollution-related, and
radiation-related symptoms and diseases, the ﬁeld of environmental health challenges the
myopic biomedical deﬁnition of health.

While all of these perspectives have been useful in addressing various issues of
health, illness, and disease, for the purposes of my dissertation, I draw on the social
construction of health and illness, the political economy of health and illness and

processes of biomedicalizaiton, which 1 now discuss in turn. Although I do not draw on

environmental health perspectives directly, this approach to understanding health and

30

illness informs my dissertation as well, in that I have adopted an environmental
understanding of health and illness, which in turn, has inﬂuenced my critique of solely
biomedical perspectives of health and illness.

Social Construction of Health and Illness

Foucault’s theorizing of knowledge and power as they related to changes in medical
practices over time in The Birth of the Clinic (1973) presented a radical challenge to
previous approaches to health and illness that conceptualized disease as the biophysical
state and illness as the social state (Annandale 2002, 34). Foucault’s social constructionist
approach argued that what we know as diseases are themselves fabrications of powerful
discourses, rather than discoveries of ‘truths’ about the body. Drawing on social
constructionism, many feminist health and illness scholars have argued that various
health problems (e.g., menopause, PMS) exclusive to women have been socially
constructed within a male-dominated medical establishment in ways that reinforce gender
inequality (Ferguson 2000; Casper 1998; Figert 1995; Lorber 1997;Ehrenreich 1978;
Leysen 1996).

While breast cancer is a medical disease, medical issues surrounding breast cancer
have been socially constructed. Breast cancer movements have played signiﬁcant roles in
socially constructing breast cancer issues. Lantz and Booth (1998) argue that the US
media discourse on breast cancer, supported by many breast cancer advocates out of a
desire to “raise awareness,” has socially constructed breast cancer as an epidemic in a
way that medical professionals did not. The rhetoric of the breast cancer movement has
now moved beyond national borders and is striving to socially construct breast cancer as

a global epidemic.

31

Related to the social construction of breast cancer as an epidemic, moreover,
breast cancer advocacy has played a signiﬁcant role in socially constructing breast cancer
risk discourse. Because medical knowledge regarding the causes of breast cancer is very
limited, breast cancer is a “contested illness,” allowing breast cancer movements to
socially construct breast cancer causes and risk in ways that strengthen their movement.
Breast cancer risk has been constructed by breast cancer advocates in the US so that all
women are “at risk” (F ishman 2000; Klawiter 2002; Fosket 2004: Simpson 2000). Within
the category of “at risk,” some women (i.e., those with a family history or genetic
predisposition to breast cancer) are constructed as “high risk,” while other women are
placed along a continuum down to “low risk” (Klawiter 2002). By constructing risk in
such a way, the biomedical breast cancer movement has increased its constituency, from
women who had already experienced breast cancer or were personally affected by breast
cancer (e.g., lost a family member to breast cancer) to all women. With the global
expansion of this breast cancer movement, breast cancer advocates are also expanding
this risk discourse on a worldwide scale.

Biomedicalization

As the biomedicalization of society increases, the biomedical paradigm continues to gain
strength, despite its inability to address many people’s concerns about health and illness
(Clarke et al. 2005). Peter Conrad (1992; 2007) argues that medicalization is a process
through which aspects of life previously understood as existing outside of the medical
realm, come to be narrowly constructed as medical problems (e.g., menopause, ADHD,
erectile dysfunction). It is often medical professionals who redeﬁne sets of behaviors or

feelings in medical terms. But, groups of laypeople experiencing certain symptoms (e.g.,

32

Gulf War veterans) or pharmaceutical companies trying to rebrand existing drugs (e. g.,
advertising birth control pills for mild acne treatment or PMS symptoms) also participate
in these processes of medicalization (Peterson 2008; Brown 2005).

With regard to diseases, like breast cancer, which never existed completely
outside of the medical realm, Maren Klawiter (2008, 313) provides an additional
understanding of medicalization. She argues that medicalization theories have tended to
ignore the

practices through which conditions that are already commonly viewed as medical

are shaped, managed and contested by and within medicine and the way the

practices through which medical conditions are continuously reproduced as

medical conditions can change over time.
Prior to the strengthening of medical power, consolidated by the organization of medical
professionals through the American Medical Association in 1847, diseases were treated
in multiple ways by different types of healers (Klawiter 2008; Conrad 2005). According
to Klawiter, breast cancer was medicalized in a variety of ways. Cancer treatment was
moved from the home to the hospital. Surgeons became the sole breast cancer experts.
Medical professionals constructed breast cancer as a curable disease. The Halsted radical
mastectomy became the “hegemonic treatment” for breast cancer (Klawiter 2008). Breast ‘
cancer patients took on the passive “sick role,” which reinforced the paternalistic role of
the surgeon and the role of the patient as the compliant child (Klawiter 2008; Conrad
2005, 30). In order to escape the conﬁnes of the “sick role” after radical mastectomy
surgery and chemotherapy, women could wear wigs, have reconstructive breast surgery
or breast prostheses implanted and return to their normal lives and duties (Klawiter 2008,

37). The formation of disease-related identities, solidarities, and social networks was

heavily constrained by processes of medicalization, which discouraged patients from

33

identifying with their disease, in order to focus exclusively on recovery and a return to
normalcy (Klawiter 2008).

Breast cancer was further reconstructed within the medical ﬁeld, as
medicalization gave way to intensiﬁed processes of biomedicalization beginning in the
19703 and 19803 and continuing today. Adele Clarke and her colleagues (2005, 442)
argue that “recently, medicalization is intensifying in new ways. Biomedicine is being
reorganized through the remaking of the technical, informational, organizational, and
hence institutional infrastructures of the life sciences and medicine, largely via the
incorporation of computer and information technologies.” Biomedicine, which Clarke
and her colleagues (2005, 442—42) deﬁne as “the increasingly technoscientiﬁc, complex,
multi-sited, multi-directional processes of medicalization,” is transforming the practices
of medicine and understandings of health and illness in the twenty-ﬁrst century.

Building on the “medical industrial complex” concept developed in the 19703,
Clarke and her colleagues (2005, 446) argue that the “Biomedical TechnoService
Complex, Inc.” typiﬁes the political economy of the current era of biomedicalization. The
corporatized and privatized research, products, and services made possible by
technoscientiﬁc innovations that further biomedicalization are emphasized by this
complex concept. “Through its sheer economic power, the Biomedical TechnoService
Complex, Inc. shapes how we think about social life and problems” (Clarke et al. 2005 ,
446). Within the political economy of biomedicalization, which consists of multinational
corporations that are spreading the biomedical paradigm and processes of
biomedicalization around the world, solutions to health problems are increasingly

corporatized and commodiﬁed.

34

Processes of biomedicalization also transform the concepts of health, risk and
surveillance, bringing discourses of risk to the forefront of medical attention. Whereas
processes of medicalization redeﬁned social problems as medical illnesses, disabilities
and/or diseases, processes of biomedicalization have redeﬁned health so that the lack of
symptoms does not necessarily indicate the lack of disease or potential disease.
Therefore, health must be maintained through biomedical surveillance and risk
assessment (Clarke et al. 2005, 446). Individuals who may otherwise appear and feel
healthy are deﬁned as “at risk” based on family history, personal behaviors, and/or results
from genetic testing. Risk is then managed through “processes of surveillance, screening,
and routine measurements of health indicators” (Clarke et al. 2005, 448). Through
biomedical screening, breast cancer was “reinvented as an invisible risk and symptomless
disease that required continuous bodily vigilance and surveillance” (Klawiter 2008, 38).
According to Klawiter (2008, 38),

Breast self-exam, clinical exam, and mammographic screening were heavily

promoted and discursively constructed as the moral duty of every woman. As this

occurred, the temporary sick role for symptomatic women was replaced by a

permanent “risk role” for all women. Biomedicalization thus reconstituted

healthy, asymptomatic women as risky subjects and transformed the disease from
an either-or condition to a breast cancer continuum.

Processes of biomedicalization have also transformed information, knowledge
production, and distribution of medical information (Clarke et al. 2005, 450). Information
on health and illness “is proliferating in all kinds of media, especially newspapers, on the
intemet, in magazines, and through direct-to-consumer prescription drug advertising”
(Clarke et al. 2005, 450). Multiple sources create and distribute health-related

information and “non-expert” individuals are increasingly expected to navigate and make

sense of various health-related messages (Clarke et al. 2005, 450). While the proliferation

35

of sources of information, knowledge production and distribution has implications for
democratizing biomedicine, the interests of the pharmaceutical industry still predominate
(Clarke et al. 2005, 450).

Finally, processes of biomedicalization have transformed bodies as well as
identities (Clarke et al. 2005, 451). The body, once viewed as immutable and the focus of
control, is reconceptualized as “ﬂexible, capable of being reconﬁgured and transformed”
(Clarke et al. 2005, 451). “Technoscientiﬁc identities” also are created through processes
of biomedicalization (Clarke et al. 2005, 452). These identities were not available prior to
certain developments in biomedical technologies. For instance, with the availability of
genetic testing, identities may shift from “healthy” to “ill,” “healthy” to “genetic carrier,”
or “low risk” to “high risk,” with the arrival of test results. These individual identities can
also develop into collective identities. For example, in the case of the breast cancer gene,
people who ﬁnd out that they are “high risk” for breast cancer may take on that illness
identity and become involved with breast cancer advocacy or join a support group for
“high risk” women. In this sense, these identity transformations can be quite profound.

My research explores processes of biomedicalization, as they are expanded to a
global scale by biomedical breast cancer advocacy organizations. Much of the literature
on biomedicalization has focused on the role of medical professionals and the
pharmaceutical industry in promoting processes of biomedicalization in order to increase
proﬁts by monitoring “at-risk” individuals, communities, and populations. By examining
biomedical breast cancer advocacy organizations, I am contributing to this literature by
examining the role of health advocacy in these processes. Furthermore, I am examining

how these processes are translated to other political and cultural contexts via biomedical

36

breast cancer advocacy organizations. Previously, the discussion of processes of

biomedicalization focused primarily on the US.

Political Economy of Health and Illness
The central tenet of the political economy of health and illness perspective is that there is

a clear contradiction between the pursuit of health and the pursuit of proﬁt (Annandale
2002, 15; Doyal 1979). I take this to signify a couple of things that are relevant to
understanding health and illness in advanced capitalist society. First, if proﬁt is the
ultimate goal in capitalist society, industrial processes will proceed with regard to the
maximization of proﬁt, while disregarding any harmful health effects of the processes.
Second, if the pursuit of proﬁt permeates all social institutions in capitalist society, then
the medical ﬁeld is also motivated by the pursuit of proﬁt, not (solely) by the pursuit of
health. As Landry and MacLean (1993, xii, as quoted in Annandale 2002, 17) state, “now
the market is ‘in’ everything and nothing is incapable of being commodiﬁed.”
Related to both of these aspects of the political economy of health and illness,
McKinlay (2005, 561) argues that,
In the past, it has been common to advocate the education of the public as a
means of achieving an alteration in the behavior of groups at risk to illness. Such
downstream educational efforts rest on “blaming the victim” assumptions and
seek to either stop people doing what we feel they “ought not” to be doing, or
encourage them to do things they “ought” to be doing, but are not. Seldom do we
educate people about the activities of the manufacturers of illness and about how
they are involved in many activities unrelated to their professed area of concern.
Although McKinlay situates “downstream educational efforts” in addressing ill health as
“in the past,” these types of educational campaigns remain quite common, while the

“upward stream” of educating people about manufactures of illness in order to create

social change remain relatively rare. Even when educational campaigns no longer “blame

37

the victim” by calling for changes in personal behaviors, health advocacy increasingly
involves the promotion of biomedical research and pharmaceutical and medical
technological solutions to disease, rather than seeking changes in the disease-producing
social structures.

A key player in the political of health and illness in terms of the commodiﬁcation
of solutions to disease, the pharmaceutical industry has become a central concern among
scholars within the political economy of health and illness. Pharmaceutical companies
once known for competing over the best scientists in order to create the next and best
drug (or so they told us), now spend most of their resources hiring the “most creative and
aggressive marketers” (Peterson 2008, 4). While the drive for proﬁt in medical research
has long been associated with little to no medical research on disease causes and
prevention, according to Peterson (2008) pharmaceutical companies are not interested in
ﬁnding the cures to such widespread ailments as cancer and heart disease either. From a
proﬁt-driven perspective, pharmaceutical companies are interested in marketing products
that can “manage” chronic diseases if taken for the duration of a patient’s life. In addition
to creating drugs to manage illnesses, pharmaceutical companies also focus on expanding
their market by “creating” new diseases, expanding the understanding of who needs a
certain drug or how that drug can be used, and ﬁnally, expanding geographically to new
markets.

One way that pharmaceutical companies seek market expansion is through the
legalization and expansion of direct-to-consumer pharmaceutical advertising (DTCA).

DTCA via openly persuasive publicity slogans—mostly on television—or

industry-funded “educational” campaigns on the identiﬁcation and lifelong drug

treatment of various troubles, is a harbinger for a major transformation in the
signiﬁcations and roles of medications in society—moving them even further out

38

of the domain of medical mystique and into the mass market as lifestyle products

{my emphasis, Cohen et al. 2005, 280).

The pharmaceutical industry, largely through shifting its efforts to marketing
drugs and particularly through the expansion of DTCA, is increasingly promoting
commodiﬁed solutions to health problems.

In addition to analyzing the pharmaceutical industry, scholars have applied the
concept of political economy speciﬁcally to breast cancer (e. g., Zones 2000), arguing that
the disease has become a source of economic gain, particularly for the pharmaceutical
and medical technology industries. In Zones’ (2000, 137) view, “once a product or
service has made its way into the marketplace, sales may be increased by appealing to
new customers.” She refers speciﬁcally to the targeting of more and more women as “at
risk populations.” Similarly, Klawiter (2002, 313) discusses breast cancer in terms of the
“pharmaceuticalization of medicine.” She argues that AstraZeneca, a large
pharmaceutical company, played a crucial role in redeﬁning breast cancer risk to include
larger numbers of women in order to market and sell their breast cancer drug, tamoxiﬁn
(Klawiter 2002). While some women’s health movements were concerned about the
direct-to—consumer advertising of this potentially dangerous drug to women in the US,
biomedical breast cancer organizations began to incorporate risk assessment discourse in
their informational materials (Klawiter 2002, 339). I utilize this work on the political
economy of breast cancer to examine the role of globally expanding biomedical breast
cancer advocacy organizations in the political economy of health and illness.

Finally, while not a health and illness sociologist, King’s (2006) understanding of

the neoliberal political economy in which health-related advocacy engages is very

39

relevant for my research. According to King (2006, xxvi), neoliberalism is “a philosophy
and a set of economic and political policies aimed at cutting expenditures on public goods
such as education, health care, and income assistance in order to enhance corporate proﬁt
rates.” She argues that Avon Foundation events focus on developing “consumer-oriented,
private, and individual responses to breast cancer in locations across the globe,” which
complements neoliberal projects, like IMF and WB structural adjustment programs that
are requiring public sector cutbacks and private sector alternatives (King 2006, 98).

I will utilize political economy of health and illness perspectives in my research
by examining the way in which biomedical breast cancer advocacy organizations globally
promote medical technology and pharmaceuticals as solutions to illness, globalizing, as
argued by King (2006), privatized and corporatized solutions to health problems. In
partnering with medical technology and pharmaceutical companies, biomedical breast
cancer organizations may expand these companies’ abilities to advertise directly to
consumers, via breast cancer events, in locations where they otherwise would not be able
to. Additionally, by creating new at-risk identities related to breast cancer, biomedical
breast cancer advocacy organizations are creating potential medical consumers for
medical technology and pharmaceutical companies. Finally, I will utilize a political
economic perspective to understand the role of SGKC’s and Avon Foundation’s elite
connections, power and inﬂuence with regard to their ability to expand globally.

Social Movement Theories
Social movements, as Buechler (2000) argues, pose challenges to the social order and,
along with many other social forces, have shaped the current context of many social

institutions within advanced capitalist society. Social movements, therefore, provide an

40

opportunity to examine human agency with regard to social change in conjunction with
the social structures (e.g., political, economic, educational, religious, medical) that
contextualize their struggles. Snow and his colleagues (2004) provide a deﬁnition of
social movements that is useful for the context of my dissertation research. According to
Snow and his colleagues (2004, 9),
In order to have an understanding of social movements that is both more inclusive
in terms of what gets counted as social movement activity, and yet more tightly
anchored institutionally and culturally, we argue that movements be considered
as challengers to or defenders of existing institutional authority-whether it is
located at the political, corporate, religious, or educational realm- or

patterns of cultural authority, such as systems of beliefs or practices reﬂective
of those beliefs.

Globally expanding biomedical breast cancer advocacy organizations challenge non-
biomedical understandings of disease that rely on alternative or non-traditional medical
practices or rely on medical intervention for symptomatic individuals only. Regardless of
the political or cultural contexts to which they are expanding, biomedical breast cancer
advocacy organizations promote breast cancer awareness, biomedical screening of non-
symptomatic populations, and individual responsibility for one’s health. Given that this
form of advocacy does not challenge existing governmental, medical, or corporate
authority, globally expanding biomedical breast cancer advocacy organizations are able
to partner with the US government, governmental and non-governmental medical
organizations, medical professionals, and corporations. Because of these partnerships
with institutional authorities, biomedical breast cancer advocacy organizations often
diverge from what are often considered social movements. Furthermore, biomedical
breast cancer advocacy organizations’ activities are not particularly disruptive, which is

often included by social movement scholars as a deﬁnitive element of social movement

41

activity. Biomedical breast cancer advocacy is also culturally signiﬁcant in that it is
promoting activities, such as athletic events and consumer spending to fundraise, which
have been developed within the US, and are now being deployed to other cultural and
political contexts in which these activities are often unfamiliar.

To understand how and why biomedical breast cancer advocacy is expanding
globally, I will utilize social movement perspectives from resource mobilization, political
opportunity structures, and framing theories. The notion of resource mobilization is
particularly useful in understanding how social movements emerge or, in this case, how
they expand. In answering the question of how social movements emerge and expand,
the resource mobilization approach focuses on “group access to and control over the
various resources necessary for effective social movement activism” (Buechler 2000, 35).
According to McCarthy and Zald (1977, 1216), “study of the aggregation of resources
(money and labor) is crucial to an understanding of social movement activity.”
Furthermore, mobilizing resources requires that social movements exhibit some level of
organization. McCarthy and Zald (1977, 1218) deﬁne a social movement organization as
“a complex, or formal, organization which identiﬁes its goals with the preferences of a
social movement or a countermovement and attempts to implement those goals.”
Resources are not merely indigenous to social movement actors and organizations; rather
they must be sought from elite individuals and institutions from outside of the movement
(McCarthy 1977). Elites control large amounts of resources and are therefore needed by
social movements. Resource mobilization will therefore be useful in explaining how
biomedical breast cancer advocacy organizations have attained the organizational

structure and ﬁnancial resources to expand beyond the US.

42

In addition to resource mobilization, the political process model, with its focus on
political opportunity structures (POS), will be useful in understanding the broader
environment in which the biomedical breast cancer movement has expanded. Using this
perspective helps shed light on why advocacy organizations expanded at the particular
time that they did and to the particular countries that they did. The political process
model is generally concerned with the ways in which the political environment shapes the
development, trajectory and outcomes of social movements. In the case of biomedical
breast cancer advocacy, I am particularly interested in the trajectory of biomedical breast
cancer advocacy with regard to its expansion beyond the US. While there are various
deﬁnitions of what constitutes the political opportunity structure, Tarrow (1998, 76-77)
provides a broad deﬁnition that captures the meaning of the concept by stating that
political opportunity refers to “consistent—but not necessarily formal or permanent—
dimensions of the political environment that provide incentives for collective action by
affecting people’s expectations for success or failure.”

Some scholars have critiqued the political process model for having a structural
bias and being overly reliant on the role of the state in explaining social movements
(Goodwin 1999; Van Dyke et al. 2004; Monis 2000). According to Goodwin and Jasper
(1999), the political process model, through the use of the popular concept of political
opportunity structures, over-emphasizes the structural aspects of political opportunities,
while downplaying or ignoring all together the ways in which political opportunities are
subjective and dynamic. Furthermore, both Goodwin and Jasper (1999) and Van Dyke
and her colleagues (2004) problematize the state-centered aspect of the political process

model. “While it is undeniably true that many social movements direct their grievances

43

and concerns to the state or state institutions, it is also the case that modern movements
target other entities, such as religion, medicine, educational organizations, professional
associations, and private employers” (Van Dyke et al. 2004, 28). While the political
process model may be useful for explaining movement mobilization that is directed at the
state, it is much less potent in its ability to explain movements that are not primarily
state-oriented. Political process theorists have tended to avoid this issue by focusing
primarily on movements that, at least to some extent, target the state.

To apply this perspective to explain biomedical breast cancer advocacy, I will
implement a broad understanding of “political environment,” that includes the medical
establishment and economic actors, such as multinational corporations and
pharmaceutical and medical technology companies. I will also pay attention to governing
bodies on national and international levels (e. g. the EU) as they may also play a role in
expanding or limiting the opportunities for this movement to expand to particular
countries.

Political opportunity scholars also have addressed the ability of social movements
to produce political opportunities. That is, in addition to responding to exogenous
political opportunities, collective action also creates opportunities. “Once collective
action is launched in part of a system, on behalf of one type of goal, and by a particular
group, the encounter between that group and its antagonists provides models of collective
action, master frames, and mobilizing structures that produce new opportunities” (Tarrow
1998, 87). The opportunities created by social movements can expand or contract the
opportunities of unrelated social movements, allied social movements,

countermovements, as well as elites (Tarrow 1998, 87-89). In the case of biomedical

44

breast cancer advocacy, given their organizational and ﬁnancial successes in the US, it is
possible that they were able to create opportunities for expansion without too much
concern for the cultural and political contexts into which they were moving. Additionally,
by expanding biomedical health advocacy to diverse political and cultural contexts, they
are likely to affect the political and economic opportunities of other health-related
advocacy organizations as well as elites, such as the corporations with which they
partner.

The notion of ﬂaming within social movement theory will also be useful in
explaining my research ﬁndings. Framing is the process of meaning construction
performed by social movement organizations (Benford 2000). By shifting their language
to the global realm, biomedical breast cancer advocacy organizations have refrained
breast cancer from a domestic to an international concern. Within the US, biomedical
breast cancer advocates framed breast cancer as a threat to all women, and therefore, by
extension as a threat to everyone through the potential illness and loss of a daughter,
wife, mother, or friend (Kolker 2005). Instead of placing blame on medical professionals,
polluting companies, or the govemment, biomedical breast cancer advocates framed
breast cancer itself as their enemy or target, and enlisted medical professionals,
corporations, and the government as allies in the ﬁght against breast cancer. In order to
defeat breast cancer, biomedical breast cancer advocates framed the solution as individual
vigilance (e.g., monthly self-exams, regular clinical exams and mammograms) and
increased funding for breast cancer research focused on detection and treatment, with the

ultimate goal of ﬁnding the cure.

45

According to Benford and Snow (2000), frame diffusion is the dynamic process
by which a social movement transmits its construction of an issue to another political
and/or cultural context. In some cases a social movement may “strategically select” and
adopt particular framing of an issue to another context or culture. In other cases, a
movement may “strategically ﬁt” its framing of an issue to another political and/or
cultural context (Benford and Snow 2000, 627). In the case of the expansion of
biomedical breast cancer advocacy, I am interested in how biomedical breast cancer
advocacy organizations have, or have not, altered their framing of breast cancer to
“strategically ﬁt” it to other political and cultural contexts in order to expand this form of
advocacy beyond the US.

Health Social Movements

Theorizing and research on health social movements has burgeoned in the past few years,
exploring how diverse health-related movements emerge and function (Allsop et al. 2005;
Brown et al. 2004; Hess 2005; Klawiter 2005; Kolker 2005; Brown 2005; McCormick et
al. 2003). Theorizing these movements is critical to this new body of literature that is
attempting to account for interlocking and overlapping interest groups. Most important
to these theoretical developments has been the work of McCormick et a1. (2003), Brown
et al. (2004) and Brown and Zavestoski (2005) who deﬁned health social movements as
organized around three main foci: (1) access to health services; (2) health inequality; and
(3) the experience of illness.

Within the body of literature on health social movements, breast cancer
movements have been conceptualized as “embodied health movements,” which address

illness experience by challenging science on etiology, diagnosis, treatment, and/or

46

prevention (Brown 2004). Embodied health movements, such as breast cancer
movements, often respond to “contested illnesses” that are either unexplained by current
medical knowledge or have purported environmental explanations that are often disputed
(Brown 2004; Brown 2005). As is the case with breast cancer movements, embodied
health movements may include constituents who are not ill, but who perceive themselves
as vulnerable to the disease (Brown 2005; Brown 2004).

Brown and his colleagues (2004) also acknowledge the diverse tactical and
organizational forms that health social movements may embrace. They present a
spectrum of tactical and organizational forms spanning from “advocacy-oriented” to
“activist-oriented.” “Advocacy—oriented” movements include groups working within the
current political economic system and the biomedical model, using tactics other than
direct, disruptive action (e.g., education), and tending not to push for lay involvement in
scientiﬁc and medical expert knowledge systems; “activist-oriented” movements, in
contrast, include groups engaging in direct action, challenging current scientiﬁc and
medical paradigms, and pursuing democratic participation in scientiﬁc or policy
knowledge production by working largely outside the current political economic system
and the biomedical paradigm (Brown 2004). While a range of breast cancer organizations
exist, spanning advocacy-oriented to activist-oriented, the globally expanding biomedical
breast cancer movement is advocacy-oriented in its approach.

The concept of “boundary movements” emerging out of the health social
movement literature is also relevant to my research. Health social movement scholars
have described many embodied health movements as “boundary movements” due to the

fact that they transcend various boundaries including boundaries between movements,

47

science and non-science, laypeople and experts, movement insiders and outsiders, and
movement organizations and corporations (McCormick et al. 2003; Brown et al. 2004;
McCormick and Baralt 2006).

Through my research, I expand on this concept of health social movements as
boundary movements, arguing that through their collaboration with the US government;
medical professionals, medical research centers, corporations, and pharmaceutical and
medical technology companies, biomedical breast cancer advocacy organizations are
actually creating “hybrid” organizations and events on a global scale. This means that in
many cases, to be discussed in detail in Chapter 5, the organizations and events within the
transnational biomedical breast cancer advocacy coalition are not strictly advocacy
organizations, events and activities, but rather advocate/diplomatic, advocate/medical,
and advocate/corporate organizations, events and activities. Given the ﬁnancial success
of this hybrid form of biomedical breast cancer advocacy, it is important to include it in
the conceptualization of forms of health social movements, as it may become an
increasing trend in health advocacy.

Additionally, health social movements have played a role in processes of
biomedicalization (Conrad 2007), participating actively in the medicalization of certain
diseases and the de-medicalization of others. The processes of medicalizing alcoholism,
post-traumatic stress disorder, Alzheimer’s disease, and most recently Gulf War Illness7
were led by social movements (Conrad 2007). In some cases, social movements have

been less successful in their attempts to medicalize illnesses, as in the case of multiple

 

 

7 After years of pressure from Gulf War veterans suffering from health problems, in 2008, a US.
collgressionally mandated panel, the Research Advisory Committee on Gulf War Veterans’ Illnesses,
conﬁrmed that Gulf War illness, as reported by veterans since the war in 1991, is a real disease that should
be treated as such by doctors and funded by veterans’ health and disability beneﬁts (Maugh 2008).

48

chemical sensitivity disorder (Kroll-Smith 1997). With regard to women’s health issues
such as menopause, menstruation and childbirth, women’s health movements have
sometimes butted heads with each other, with some supporting increased medicalization
as a means of legitimating illness symptoms, and others challenging medicalization,
emphasizing these processes as “natural” parts of women’s lives, not in need of medical
intervention (Westfall 2004; Leysen 1996; Ferguson 2000).

In the case of biomedical breast cancer advocacy, advocates working in the US
have promoted a biomedical model of the disease to the exclusion of environmental
factors that may contribute to breast cancer incidence (Eisenstein 2001; Zavestoski et al.
2004). Having achieved great ﬁnancial success in the US (King 2006; Klawiter 2008),
these advocacy organizations are now expanding globally and playing a role in processes
of biomedicalization on an international scale. While breast cancer is, without dispute, a
disease that needs to be addressed by the medical establishment, both within the US and
globally as well, it is also a disease whose increasing incidence is largely unexplained by
sole reliance on medical science.

My research will expand current understanding of the role of health social
movements in processes of biomedicalization by examining biomedical breast cancer
advocacy organizations on a global scale. These organizations promote a biomedical
understanding of breast cancer, emphasize all women’s status as “at-risk” for the disease,
and encourage medical surveillance in the form of clinical breast exams and regular
mammograms. Working collaboratively with medical professionals, medical research
centers, hospitals, and pharmaceutical companies, biomedical breast cancer advocacy

orgarrizations play an integral role in creating awareness about biomedical breast cancer

49

screening and treatment and creating new medical consumers. Finally, health social
movements, currently, have been examined within individual countries, primarily within
the US and the UK. Therefore, the examination of transnational biomedical breast cancer
advocacy will expand the examination of these organizations beyond national borders,
contributing to our understanding of how health advocacy, particularly biomedical health
advocacy, translates to other political and cultural contexts.

Transnational Social Movements, Networks, and Coalitions

Given the rapidity with which international political, economic and socio-cultural inter-
connections are proliferating through processes of globalization, social movements are
increasingly transcending national borders in order to confront issues that are not
conﬁned by national boundaries. According to transnational social movement scholars, in
the context of an increasingly globalizing political economy, we can expect that
“collective actors in transnational space will be a feature of the contemporary world and
will continue to expand in number and importance” (Khagram et al. 2002, vii).
Transnational movements, networks, and coalitions, are signiﬁcant social actors in that
they have the potential to transform both domestic and international politics by creating
issues, mobilizing new constituencies, and altering understandings of interests and
identities (Khagram et al. 2002, vii). To investigate this trend, social movement scholars
have amended state-centric social movement theories, which largely theorized social
movements conﬁned within national boundaries, to better understand the increasingly
transnational nature of much social movement activity (Eschle 2001; Farro 2001; Keck,
1998; Khagram et al. 2002; Sikkink 2002; Moghadam 2001; Tarrow 2005; Farro 2001 ;

Keck 1998; Khagram 2002; Sikkink 2002; Moghadam 2001; Tarrow 2005).

50

Transnational social movement (TSM) scholars are careful to acknowledge
multiple forms and meanings of “globalization.” Globalization refers to a diversity of
economic, political, and socio-cultural trends of increasing inter-connections among
economic institutions, governing bodies, and cultural phenomena (McCarthy 1997;
Pieterse, 2001). TSM scholars have primarily focused on what they variously refer to as
“neoliberal globalization”, “economic globalization” or “corporate-dominated
globalization” (Evans 2005; Bennett 2005; Eschle 2001), given that this is the form of
globalization that many contemporary TSMs are challenging (Bennett, 2005). According
to Pieterse (2001, 22), “to distinguish contemporary globalization from long-term trends
it may be appropriate to speak of accelerated globalization. Accelerated globalization
coincides with the prominence of neoliberalism and the drive to free markets.” Similarly,
della Porta and Tarrow (2005, 2) argue that there is a “shift in the axis of power from
politics to the market, with neoliberal economic policies increasing the power of
multinational corporations and reducing the capacity of traditional state structures to
control them.” To counter neoliberal globalization, Evans (2005, 655) argues that social
movements have “harnessed the growth of transnational connections” to construct “more
equitable distributions of wealth and power and more socially and ecologically
sustainable communities.” This trend in social movements is often referred to as
“counterhegemonic globalization” or “globalization from below” (Evans 2005; Khagram
2002; Pieterse 2001). Much TSM scholarship thus far has been biased toward progressive
movements countering globalization. This scholarship has ﬁ'uitfully explored how these
social movements have “harnessed” transnational connections, using them as

opportunities to counter current neoliberal economic trends. At the same time, research is

51

lacking on how transnational social movements may actually utilize neoliberal economic
institutions and trends to further their goals. My research will help ﬁll this gap.

TSMs, via their respective organizations (TSMOs), work toward a variety of
social change goals. Nevertheless, social movement scholars have tended to focus on the
most populous transnational movements. The issues that have generated the most
transnational activity are “also those that have achieved wide support among national
groups in Western democracies” (Smith 2004, 320). The transnational movement for
human rights has consistently been the most populous TSM. Other large TSMs include
the “anti-globalization” or “global justice” movement, women’s rights movements, peace
or anti-war movements, and the environmental movement. In some cases, claims
originally deﬁned within national boundaries are “refrarned” in order to ﬁt within
transnational discourses (Smith 2004, 321). The literature on TSMs is lacking in terms of
research on transnational health social movements. My research on transnational
biomedical breast cancer advocacy, utilizes concepts from TSM literature, while
broadening the types of movements that have been studied.

In addition to the diversity of issues addressed by TSMs, there are a variety of
forms of transnational collective action. Many TSM scholars have focused their attention
on transnational advocacy networks (TANs), which consist of informal connections
between non-state actors linked across national boundaries. Network participants are
bound together by “shared values, dense exchanges of information and services, and
common discourses” (Keck 1998; Khagram et al. 2002, 7). While TANs primarily exist
for the exchange and shared use of information, transnational coalitions involve a greater

level of transnational coordination than is present in transnational networks.

52

Transnational coalitions are sets of actors linked across national boundaries who
coordinate shared strategies or sets of tactics to publicly inﬂuence social change
(Khagram et al. 2002). Transnational campaigns are shared strategies or sets of tactics
utilized by transnational coalitions and they can include so-called “non-institutionalized”
tactics (e.g., boycotts, protests, civil disobedience) or a combination of institutionalized
and non-institutionalized tactics, as is often the case with domestic social movements

(T arrow 1998). Finally, transnational social movements (TSMs) are “sets of actors with
common purposes and solidarities linked across country boundaries that have the
capacity to generate coordinated and sustained mobilization in more than one country to
publicly inﬂuence social change” (Khagram et al. 2002, 8).

In addition to these “pure” forms of transnational collective action, consisting
solely of non-state activist or advocacy organizations, TSM scholars have also noted the
existence of mixed actor coalitions (MACS). Although NGOs and social movements are
the Primary actors within these transnational coalitions, (parts of) states and
intergovernmental organizations, as well as other non-state actors such as foundations,
research institutions, and/or corporations could also be included (Khagram et a1. 2002).
This deﬁnition is more expansive and inclusive, as opposed to transnational coalitions
and nitlrworks, which only include domestic and international NGOs and social
movements. According to Khagram and colleagues (2002, 11), the non-governmental
5691013 of which TSMs and NGOs are a signiﬁcant part, represent a third sector of
SOCiCtY: “distinct from, but interacting with, government and business, in which the
characteristic form of relation is neither authority or hierarchy, nor the market, but rather

the informal and horizontal network.” Additionally, while Khagram and his colleagues

53

(2002, 11), like many other social movement scholars, argue that the non-governmental
sector, and speciﬁcally, social movements, represent a distinct sector of society, I have
found that in their efforts to globally expand, biomedical breast cancer advocacy
organizations are intricately tied to governmental, medical, and corporate sectors, in ways
that blur the boundaries between their interests, identities, and activities.

Transnational social movements and INGOs are increasingly emerging as
signiﬁcant actors in the global political economy. TSMs and INGOs are “transforming
global norms and practices” (Khagram et al. 2002). Scholars of TSMs and INGOs stress
the increase in new non-state actors, new arenas for action, and the blurring of
distinctions between domestic and global levels of politics (Khagram et al. 2002). Rather
than theorizing TSMs as completely new phenomena, social movement scholars tend to
view transnational movement dynamics as extensions of national social movements. As
stated by Smith (2004, 320), “while global integration has altered dramatically the arenas
of political struggle, there are tremendous continuities in how social movements operate
and interact with authorities.” Social movement scholars have also noted that there is a
trend in which national groups are increasingly participating more in transnational
networks and coalitions “as they discover that achieving their organizational aims require
engagement at the transnational level” (Smith 2004, 320).

Structures of opportunities for transnational advocacy are similar to those for
state-based advocacy, in that the potential for inﬂuence is affected not only by
governmental structures, but also by social and cultural contexts including values, beliefs,
and patterns of behavior that movements seek to change (Smith et al. 1997, 70). Many

studies of TSMs, however, focus exclusively on social movement activity in explicitly

54

“political” arenas. As stated by Smith and colleagues (1997, 70), “the ‘deep politics’ of
shaping individuals’ thinking and action on environmental, peace, development, and
other issues clearly occupy much, if not most, social movement energies.” Nevertheless,
it is these efforts that are often neglected by social movement scholars. My research will
contribute to this literature by examining how globally expanding biomedical breast
cancer advocacy organizations work to shape how women in other countries think and act
regarding breast health, cancer risk, medical surveillance, and health advocacy.
Biomedical breast cancer advocacy organizations have not shifted to a global scale
primarily to inﬂuence transnational governing bodies (e. g., the European Union), to
challenge transnational economic organizations (e.g., IMF, WTO), or to confront
multinational corporations. Rather they are committed to the “deep politics” of shaping
women’s understandings of health and illness by promoting a global biomedical breast
health agenda.

Transnational social movements often attempt to draw upon preexisting
institutional structures in mobilizing around particular issues. TSMOs usually draw on
preexisting organizations that are tackling similar issues, rather than reinventing the
wheel by trying to recruit individuals who are unafﬁliated with any organization. At the
same time, social movement scholars have noted that social movement organizations also
“have strong incentives to compete with one another for resources, constituents, and
legitimacy” (McCarthy 1997, 250).

Transnational arenas of engagement frequently involve global conferences and
meetings. These annual or bi-annual conferences provide opportunities for advocates

from different countries to meet in person to strategize for their transnational campaign.

55

These types of meetings are obviously expensive and resource-intensive in terms of
planning and coordination. Therefore, in addition to global conferences and meetings,
transnational social movements conduct most of their organizing over the internet. Many
transnational advocacy organizations also sponsor formal training sessions “to help
reduce the costs of mobilizing around transnational issues” (Smith 2004, 326).

In pursuing their goals, transnational advocacy organizations, networks, and
coalitions employ mobilizing and action strategies. According to Smith and her
colleagues (1997, 71), mobilizing strategies “attempt to attract new activists and
resources for the cause.” Action strategies, on the other hand, are the “activities that
social movements employ in order to inﬂuence policy” (Smith et al. 1997, 71). TSMs,
like national movements, have to make decisions about their repertoires of contention, or
which types of strategies they will employ. Strategic repertoires “can be conceived of as
some mix of public education, direct aid to victims of injustice, and attempts to change
structures directly” (McCarthy 1997, 257). In the case in which movements are not
focused on inﬂuencing policy, per se, action strategies are employed in order to inﬂuence
potential allies, participant identities, socio-cultural norms, and/or various priorities or
values (e.g., economic, educational, religious, health).

Transnational social movements also engage in strategic framing processes. As
stated by McCarthy (1997, 245), “if the work of strategic framing is difﬁcult at the
national level, it is far more difﬁcult at the transnational level.” Transnational movements
must attempt to construct frames that resonate in diverse cultural settings and to promote
frame bridging, which is “the linking of new mobilizing frames with existing cultural

materials” (McCarthy 1997, 245). According to social movement scholars, one of the

56

most successful transnational framing efforts in the recent period has been the “creation
of a common transnational conception of human rights” (McCarthy 1997, 245).

An important question regarding transnational social movements is what leads
advocates to globalize their struggles. Scholars of transnational advocacy campaigns and
movements have identiﬁed “important linkages between social movement actors and
global institutions, such as the United Nations or European Union, that encourage
transnational activism” (Smith 2004, 325). Additionally, “modeling” or “diffusion” refers
to the adoption of norms or forms of collection action or organization in one setting that
have been developed or used in another (Smith 2004, 325). Finally, national social
movements are likely to expand transnationally if they have reason to believe that doing
so will further their goals (Reitan 2007).

According to Bennett (2005), diffusion is the oldest form of transnational
contention. Diffusion involves advocates in one country or region adopting or adapting
the organizational forms, collective action frames, or targets of those in other countries or
regions. Diffusion processes may, but need not, involve connections across borders
(Bennett 2005). Tarrow (1998) describes a variant of diffusion, called “brokerage,”
through which groups or individuals deliberately connect actors from different sites of
contention. In general, social movement research indicates that “sustained diffusion
processes both require and help to produce transnational networks and identities” (Della
Porta 2005).

Transnational social movements are not only shaped by globalizing forces, they
also are agents affecting current political, economic and socio-cultural trends.

Transnational social movements can be important agents of global change in a variety of

57

ways (Kriesberg, 1997; Pieterse 2001). While transnational social movements, networks
and coalitions, like their national counterparts, are rarely “successful,” if success is
strictly deﬁned as achieving speciﬁc policy changes, there are several ways transnational
advocacy can and does inﬂuence transnational politics, economics, and culture.
Transnational advocacy often focuses the attention of elites and the general public on
particular global issues or problems (Smith et al. 1997, 73). In many cases, transnational
social movements foster new transnational identities among their constituents.
Additionally, transnational social movement organizations provide a network of relations
for “the diffusion of ideas and practices, thereby facilitating mobilization for movement
goals” (Kriesberg 1997, 14). Transnational social movement organizations also affect
global change, in some cases, by establishing intergovernmental institutions, placing
different people in decision-making ofﬁces, and “providing particular goods or services
through the market place or through public or private nonproﬁt organizations” (Kriesberg
1997, 15). Nevertheless, TSMOs are “only one of many global actors, and they are often
relatively powerless when compared to other global actors such as governments,
multinational corporations, and international banking institutions” (Kriesberg 1997, 16).
Transnational social movements “help shape transnational policies in ways such
as mobilizing support, broadening participation, sustaining activity, framing issues, and
implementing policies” (Kriesberg 1997, 16). In some cases TSMOs try to inﬂuence
international governmental organizations and other international non-governmental
organizations by direct contacts. They usually also work at the national level to inﬂuence
officials, national organizations, and the public at large. Transnational social movements

shape global policy by “helping mobilize support for particular policies, helping sustain

58

attention on critical global problems, helping frame issues and setting the policy agenda
and some carry out transnational policies” (Kriesberg 1997, 17-18). Finally, within
TSMOs and transnational campaigns, there is evidence to suggest that new leadership
skills and advocate identities are generated (Smith, 2004, 326).

While the transnational social movement literature has expanded signiﬁcantly
over the past decade, it remains limited in some signiﬁcant ways. There is a bias in the
literature toward progressive TSMs that are countering neoliberal globalization.
Additionally, there remains a bias in the TSM literature, similar to that in the literature on
national social movements, focusing on movements that are directed toward political
(e.g., EU) and economic (e.g., WTO, IMF) institutions. Finally, the literature is
completely lacking with regard to analyses of transnational health advocacy. My
research, therefore, will contribute to this literature in a number of ways. By examining
transnational biomedical breast cancer advocacy, I will employ concepts from
transnational social movement theorizing to understand how health advocacy develops on
a transnational scale. Rather than positioning themselves against neoliberal globalization,
biomedical breast cancer advocacy organizations play a role in neoliberal trends by
promoting individual responsibility for one’s health and promoting a consumer model of
health advocacy and health-related behavior. Finally, biomedical breast cancer advocacy
does not focus on political and corporate targets; instead, these advocacy organizations

align with government agencies and corporations to further their goals.

59

CHAPTER 3
THE RESEARCH PROCESS

The ﬁndings presented in this study are based on twenty-four semi-structured interviews,
qualitative content analysis, and participant observation. In this chapter I begin with a
discussion of my research design as it relates to my research objectives. I then discuss the
principles of feminist research methodology that I drew on for this project. Next I discuss
the rationale behind the selection of organizations and research sites for this project.
Finally, I discuss my entry into the research sites and conclude by elaborating on my

particular research methods and data analysis techniques.

RESEARCH DESIGN

The methodological approach taken in my research is that of an intrinsic case study (Berg
2004). By this I mean that I am utilizing the global expansion of biomedical breast cancer
advocacy because it presents a unique and interesting case in which (1) US-based
biomedical advocacy organizations are expanding to other countries, (2) transnational
health advocacy coalitions may be playing a signiﬁcant role in the global political
economy of health and illness and processes of biomedicalization, and (3) theoretical
conceptualizations of health social movements and transnational coalitions are
challenged. By better understanding this particular case, I will be able to contribute to
theoretical understandings of the social construction of health and illness, processes of
biomedicalization, the political economy of heath and illness, health social movements,
and transnational advocacy coalitions. While ﬁndings based on this case will not be

generalizable to other health social movements, there does seem to be a trend in the US

60

toward single-disease advocacy organizations that rely on fundraising and awareness
campaigns.8 Biomedical breast cancer advocacy organizations led this trend, and
therefore, may be the precursors to an internationalizing shift to this form of advocacy as
well. Therefore, the results of this case study speak to a growing pattern among health

advocacy organizations.

Flgure 3.1. Conceptual Framework

 

 

 

 
    
 
 
 

 

 

 

 

Medical Community
Technologies Governing M33
Treatments Transnatronal (e.g., EU)
Research National
Medical Professionals

 

 

International Biomedical
Breast Cancer
Advocacy Organizations

 
      
 

 

Global Political Economy of Health and Illness

 
  

 

 

   

Pharmaceutical Partners] Sponsors Other Corporate
e. g. AstraZeneca, Johnson & Johnson Partners/Sponsors

e.g. Samsrmg, Ford

      
 

 

 

 

 
 

 

 

 

 

’ The single-disease biomedical model of advocacy, like that of biomedical breast cancer advocacy, is
proliferating, developing around such illnesses as autism, testicular cancer, ovarian cancer, spinal muscular
atrophy, and heart disease. While other forms of health advocacy organized around universal healthcare
and environmental justice issues remain present, single-disease biomedical advocacy organizations, by
engaging in fundraising and awareness campaigns often through partnerships with corporations, utilizing
“cause marketing” as well as public walking, running and racing events, are often publicly in the forefront
of disease advocacy.

61

In Figure 3.1, I provide a visual representation of the conceptualization of my dissertation
research. I depict therein the global political economy of health and illness, as I
understand it for this study, as encompassing multiple actors, including the medical
community, governing bodies, multinational corporations, both directly and indirectly
related to health and illness, and health advocacy organizations. Within the global
political economy of health and illness, I am interested in transnational health advocacy
organizations, with particular emphasis in this study on the interconnectedness of
globalizing biomedical breast cancer advocacy organizations with other actors in the
global political economy of health and illness. These organizations are intricately linked
to the international medical community, national and transnational governing bodies, and
multinational corporations, thereby forming transnational health advocacy coalitions.
With regard to the medical community, there are intersections between breast cancer
advocacy organizations and medical professionals, who often have been involved on the
boards of advocacy organizations, thereby becoming an integral element of the
transnational biomedical breast cancer coalition. In the case of the global expansion of
biomedical breast cancer advocacy in particular, medical professionals have been
involved in establishing international afﬁliates of SGKC in Italy, Puerto Rico, and
Germany. The BHGI is another example in which medical professionals are involved
with global advocacy organizations, as the initiative was established through a

partnership between SGKC and the Fred Hutchinson Cancer Research Center.

In addition to the intersection among medical professionals, research centers and
biomedical breast cancer advocacy organizations, a mutually beneﬁcial relationship also

exists between these organizations and the medical community for the development of

62

new breast cancer technologies and treatments. Biomedical breast cancer advocacy
organizations, through their global expansion, are increasing funding for medical
research, spreading awareness about the medical treatments and technologies that
currently exist, and trying to expand their reach to additional populations. Therefore,
globally expanding biomedical breast cancer advocacy organizations have the potential to
increase and/or accelerate processes of biomedicalization through their relationships with

the medical community.

Governing bodies also play a role in the global political economy of health and
illness and interact with globally expanding biomedical breast cancer advocacy
organizations. Governing bodies, on national and transnational levels, have been targeted
by biomedical breast cancer advocacy organizations to increase funding for breast cancer
research and to enact legislation to ensure proper treatment of all women with breast
cancer (Casamayou 2001; Love 1997). Governing bodies are signiﬁcant, therefore, with
regard to their role in ﬁnancially supporting the global expansion of biomedical breast
cancer advocacy organizations as well as their role in establishing breast cancer and other

health-related policies.

Finally, corporate partners/sponsors are also part of the global biomedical breast
cancer coalition. In this model, I have separated non-medical corporate partners/sponsors
and pharmaceutical and medical equipment partners/sponsors. While both play a role in
the global expansion of biomedical breast cancer advocacy, I look at them separately
because the pharmaceutical industry and producers of medical equipment have clearer
ties to biomedical breast cancer advocacy organizations’ agendas than do cosmetics or

automobile companies, for example. All corporate sponsors play a role in the

63

transnational coalition by ﬁnancially supporting the expansion of biomedical breast
cancer advocacy organizations. In addition to ﬁnancially supporting the global expansion
of biomedical breast advocacy organizations, pharmaceutical and medical equipment
partners/sponsors also participate in global biomedical breast cancer advocacy events,
promoting breast cancer awareness along with their relevant treatments and technologies
(King 2006).

Conceptualization and Operationalization

As discussed in Chapter 1, breast cancer advocacy is complex and multi-faceted. To
differentiate forms of breast cancer activism and advocacy, scholars have used terms such

9’ ‘6

as “environmental breast cancer movement, political breast cancer movement,” and
“mainstream breast cancer movement” (McCormick 2006; Zavestoski et al. 2004). I will
use the term “biomedical breast cancer advocacy” throughout my dissertation. This is the
type of advocacy that is expanding globally. In the US, it is more often known simply as
the breast cancer movement, the pink ribbon movement, or mainstream breast cancer
advocacy. Nevertheless, using the term “biomedical” speciﬁes the actual form of
advocacy that the organizations promote.

While I draw on the social movement literature to theorize the expansion of
biomedical breast cancer advocacy organizations and the development of transnational
biomedical breast cancer coalitions, I will refer throughout my dissertation to “advocacy
organizations” and “advocates,” rather than to social movement organizations, social
movement actors, and activists. The distinction among interest groups, social movements,

and nonproﬁt organizations, and even their corporate sponsors/partners is becoming

increasingly blurry (McCormick 2006; Andrews 2004). Given that this is the case, I will

64

adopt Andrews and Edwards’ (2004, 481) deﬁnition of advocacy organizations as
organizations that “make public interest claims either promoting or resisting social
change that, if implemented, would conﬂict with the social, cultural, political, or
economic interests or values of other constituencies and groups.” Biomedical breast
cancer advocacy organizations, therefore, will include SGKC, which deﬁnes itself as “the
leader of the global breast cancer movement,” but is seen by some as a fundraising or
philanthropic nonproﬁt organization (King 2006). This deﬁnition will also encompass the
Avon Foundation and its breast cancer-related projects, even though it was established by
a corporation. A strict deﬁnition of social movement organizations would not be able to
encompass these organizations; however, it is crucial that they are both included because
they play important roles in the furthering of global biomedical breast cancer advocacy.

With regard to my overarching theoretical question, I will rely on Brown and
Zavestoski’s (2005, 1) deﬁnition of health social movements as “collective challenges to
medical policy, public health policy and politics, belief systems, research and practice
which include an array of formal and informal organizations, supporters, networks of
cooperation and media.” In referring to global health social movements, I mean that the
health social movements to which I refer may be active primarily within national
boundaries, but they have created transnational coalitions and are global in the sense that
the organizations originated in the US, but are expanding to other political and cultural
contexts.

My use of processes of biomedicalization draws on the work of Conrad (1992;
2007) and Clarke and her colleagues (2005). Conrad (2007, 5; see also 1992) deﬁnes

medicalization as a process in which a problem is deﬁned “in medical terms, using

65

medical language, understood through the adoption of a medical framework, or ‘treated’
with a medical intervention.” Clarke and her colleagues (2005, 444) describe
biomedicalization as an extension of medicalization in which medicine is no longer only
capable of exerting clinical and social control over particular conditions. Processes of
biomedicalization are capable of transforming bodies and lives through the expansion of
biomedical organizations, infrastructures, knowledges, and clinical treatments.
Speciﬁcally, I am concerned with processes of biomedicalization that redeﬁne what it
means to be healthy or ill (e. g., creating “risky subjects”) and that promote risk
assessment, medical technology and treatment options as the necessary responses to
dealing with previously-deﬁned healthy populations.

My understanding of the global political economy of health and illness is based
on Clarke and her colleagues (2005, 446) concept of the “Biomedical TechnoService
Complex, Inc.” According to Clarke et al. (2005), multinational corporations are
spreading the biomedical paradigm and processes of biomedicalization around the world
with solutions to health problems that are increasingly corporatized and commodiﬁed, as
opposed to public health- or prevention-oriented interventions. My model, however,
focuses on the role of globally expanding biomedical breast cancer advocacy
organizations in order to better understand the role that these under-examined
organizations may play in the global political economy of health and illness.

Deﬁnition of Terms

MedicaLl Community: This refers to facilities, treatments, and technologies that are

designed to treat disease as well as professionals who work within such facilities (e.g.

doctors, physician’s assistants, registered nurses, researchers).

66

Governing Bodies: These are formal national and transnational political structures
that deﬁne health priorities, fund health advocacy organizations, partner with health
advocacy organizations, and are targets of health advocacy organizations. For the
purposes of this study, I am concerned only with the Puerto Rican government, US
government, Italian government, and the European Union.

Glojrlly expanding Biomedical Breast Cancer Advocacy Organizations: These
are formal groups that are established in more than one country and work to promote
breast cancer awareness through the promotion of breast self-exams, clinical exams and
mammographic screening and raise funds to support breast cancer research focused on
detection, treatment, and ﬁnding a cure.

_Ph_arm_aceutical_ and Medical Equipment Partners/Sponsors: These are
pharmaceutical and medical technology companies that have publicly and ﬁnancially
supported a globally expanding biomedical breast cancer advocacy organization through
direct contributions, cause-marketing, and/or event sponsorship.

Non-medicﬂorporate Partners/Sponsors: These are companies that are not part
of the medical community but that have publicly and ﬁnancially supported a globally
expanding biomedical breast cancer advocacy organization through direct contribution,
cause-marketing, and/or event sponsorship.

Transnational Biomedical Breast Caﬂer Advocacy Mixed Actor Coalitions:
These include the interconnections among biomedical breast cancer advocacy
organizations, the medical community, governing bodies, pharmaceutical
partners/sponsors, non-medical corporate partners/sponsors, and any other

nongovernmental organizations partnering with biomedical breast cancer advocacy

67

organizations in more than one country. These collaborators work together for the shared
purpose of increasing breast cancer awareness through the promotion of breast self-
exams, clinical exams and mammography and raising funds to support breast cancer
research focused on detection, treatment, and ﬁnding a cure. Actors in the coalition may

beneﬁt from their participation in other ways as well.

FEMINIST RESEARCH METHODOLOGY

My research design is based on principles of feminist research methodology, particularly
with regard to the relationship between research and advocacy and researcher reﬂexivity
(DeVault 1996). I view myself as a feminist researcher/activist. While I have not been
directly involved in breast cancer activism, I support feminist— and environmentally
oriented approaches to breast cancer prevention. I view breast cancer as one chronic
disease among many both chronic and infectious diseases that affect women globally,
thereby demanding attention, but not necessarily the disproportionate amount of concern
that it has received to the marginalization of other diseases. Given this perspective, I hope
to use my research not only to inform theory, but to inform practice. I will share my
ﬁndings with the organizations that have contributed to my research as well as any other
organizations that may be interested in them. I would also like to publish some of my
ﬁndings in outlets such as MAMM: Women, Cancer and Society, a magazine dedicated to
breast cancer for a lay audience, and The Breast Journal, an academic journal that
addresses breast cancer primarily from a medical perspective, with some articles on
advocacy. In this respect, I hope that my research will contribute to breast cancer

advocacy in particular, and to women’s health advocacy in general.

68

As a self-reﬂexive researcher, I am aware not only of my views on particular
forms of breast cancer advocacy, but also on the motivation behind my chosen research
agenda. Given that my mother was diagnosed with breast cancer when she was 38 years
old, and I was eight, and died when she was 42, in a signiﬁcant way breast cancer has
shaped my life. With the discovery of the link between BRCA I and BRCA II gene
mutations with susceptibility to breast cancer in the early 19903, I was confronted by the
predominant rhetoric of genetic risk that surrounded the disease. Frustrated by the
emphasis on genetic factors that were found to only account for about ﬁve to ten percent
of breast cancer cases (Steingraber 2000; Simpson 2000; Eisenstein 2001), I became
increasingly interested in breast cancer activism and particularly in critiques of
biomedical breast cancer advocates’ sole reliance on biomedical explanations of breast

cancer incidence.

During my research, almost all of the people I interviewed asked about my
interest in breast cancer advocacy. The fact that my mother died of breast cancer seemed
to legitimate my interest in this area of research and allowed the participants to treat me
as an “insider” in the sense that they seemed more willing to talk to me and invite me to
more of their events than they might otherwise have done once they knew about this
aspect of my history.

Situated Knowledges

My research is also informed by Haraway’s (2004) notion of “situated knowledges.”
Evolving out of standpoint theory, situated knowledge provides yet another approach to
feminist conceptions of knowledge creation. Like standpoint theory, situated knowledge

is based on the notion that knowledge is socially located. Haraway (2004) argues that

69

knowledges are localized and embodied and that they are not simply about a single static
identity, as standpoint theory suggests, but rather that they are complex and changing all
the time. According to Haraway (2004: 173), “feminist objectivity means situated
knowledges. Feminist objectivity is about limited location and situated knowledge, not
about transcendence and splitting of subject and object.” Haraway argues that the notion
of complete vision, or seeing everything, is not possible and what really occurs is partial
vision. In advocating situated knowledges, Haraway critiques Harding’s notion of
standpoint theory’s privileging of subjugated standpoints (Haraway 2004; Harding 2004).
She argues that it is more important that all knowledges be viewed as partial and
accountable, and even subjugated standpoints need to be subject to evaluation and
deconstruction.

An important aspect of situated knowledge is that the researcher or “knowing
self” is partial. In other words there is not a solid consistent identity in which any person
is completely privileged or subjugated (Haraway 2001). Haraway argues that it is very
important that the researcher be accountable for her or his particular social location by
acknowledging the partiality of the knowledge produced. Indeed, according to Haraway
“we do not seek partiality for its own sake, but for the sake of the connections and
unexpected openings situated knowledges make possible. The only way to ﬁnd a larger
vision is to be somewhere in particular” (Haraway 2004, 180).

Based on this understanding of “situated knowledges,” I have chosen to use three
qualitative methods, in the hope that while they all offer partial perspectives, they will
jointly contribute to illuminating the answers to my research questions. As noted below,

in the section on interviews, I also attempted to interview a wide-range of advocates from

70

different organizations, including ones who are not directly engaged with global
biomedical breast cancer advocacy organizations, in order to better understand this

phenomenon from multiple partial perspectives.

SELECTION OF ORGANIZATIONS AND RESEARCH SITES

To explore the case of the global expansion of biomedical breast cancer advocacy, I
chose to focus my research on Susan G. Komen for the Cure and the Avon Foundation.
As discussed in Chapter 1, Nancy Brinker founded SGKC, formerly the Susan G. Komen
Foundation, in Dallas, Texas in 1982 after her sister, Susan Komen, died of breast cancer
at the age of 36 (Brenner 2000; Casamayou, 2001). It is the largest breast cancer
advocacy organization in the world to date (King 2006). In 1955, the Avon Company
established the Avon Foundation as a nonproﬁt organization “dedicated to the betterment
of the lives of women and their families” (Avon Foundation 2008). Thirty-seven years
later, the Avon Foundation launched the Avon Breast Cancer Crusade in order to target
their mission toward a disease that almost exclusively affects women. These two
organizations are leading the global expansion of biomedical breast cancer advocacy.

I conducted my research in the US, the US Commonwealth of Puerto Rico, and
Italy. Within the US, I conducted interviews with advocacy leaders within SGKC, Avon
Foundation, and the Breast Health Global Initiative (BHGI), which was co-founded by
SGKC and the Fred Hutchinson Cancer Research Center (FHCRC), who were directly
involved in decision-making and program development regarding the global expansion of
their respective organizations. In September 2007, SGKC sponsored Ignite the Promise
Global Advocate Summit, the ﬁrst global breast cancer advocacy summit of its kind, in

Budapest, Hungary. The event was closed to the general public. Participants in the event

71

included the organizers from SGKC, representatives from the BHGI, advocates working
with SGKC in the US who applied to attend the summit as delegates and who were
selected by SGKC to attend the event, as well as international breast cancer advocates
selected as delegates by SGKC based on their desire to work with SGKC internationally.
I tried to gain access to the summit for my dissertation research through SGKC and the
BHGI, but was not granted access, nor would they provide me with a list of delegates
attending the summit. I therefore conducted interviews with delegates whose names I
found on the SGKC website in reports from the summit. I contacted the six delegates who
I was able to ﬁnd contact information for using a Google web search and received

responses from two international delegates who I was able to interview over the phone.

I also collected the majority of documents for my content analysis in the US.
Press releases, news stories, summit reports, annual reports, ﬁnancial reports, and
published articles from SGKC, the Avon Foundation, and the BHGI websites supplied a
great deal of information regarding the global expansion of these organizations. Finally, I
also conducted participant observation at three RFTC events in Lansing, MI between

2006 and 2009.

I selected the US Commonwealth of Puerto Rico and Italy because they are two of
the three current SGKC international afﬁliate locations and also have Avon Foundation
offices and host Avon Foundation events.9 The third location that I could have selected

because it also has both SGKC and Avon Foundation ofﬁces and events was Germany;

 

9 At the time that I began my research, the BHGI did not have any international locations in which it was
working. The BHGI, a partnership between SGKC and the Fred Hutchison Cancer Research Center, is
working to develop best practices for breast cancer care in limited resource countries. They are currently
developing programs in South America, information about which I was able to include in my documental
data.

72

however, because I would have needed to hire a translator to conduct research in

Germany, I chose to omit it from my study. Additionally, my research funds were limited
and I was only able to work in two research sites outside of the US. Puerto Rico and Italy
are signiﬁcantly distinct from each other, as well as from the US, thereby allowing me to

adopt a comparative perspective (see Table 3.1).

In Table 3.1, I have highlighted some of the relevant ways in which my research
sites vary, allowing for a comparative perspective. The US, Puerto Rico and Italy are
distinct in a variety of ways that are useful for a comparative perspective regarding
biomedical breast cancer advocacy. They are located in three different geographic
regions, allowing me to draw comparisons between North America, the Caribbean, and
Southern Europe. With regard to healthcare coverage and access to mammography
speciﬁcally, which is one of the main foci of biomedical breast cancer advocacy, they
also vary.10 Breast cancer incidence rates are also signiﬁcantly different among these
three countries, with the US having a comparatively high incidence rate, Italy having a
moderately high rate, and Puerto Rico a decidedly low rate. With regard to breast cancer

advocacy, in particular, they also represent unique cases.ll While my dissertation is

 

'0 The US and Puerto Rico both have privatized healthcare systems with limited government assistance in
the form of Medicaid and Medicare. Puerto Rico has a higher percentage of people lacking health insurance
as well as a higher percentage of people with government assistance. When people are covered by private
or public health insurance in the US and Puerto Rico, the large majority of insurance plans cover yearly
mammograms for women aged 40 and over. Younger women can also have mammograms covered if they
have evidence of a signiﬁcant family history of breast cancer or a history of other benign breast disease. In
Italy, there is a national health plan, so everyone has healthcare. The healthcare plan covers bi-annual
mammograms for women between the ages of 50 and 69. Women outside of this age range or who want to
be screened annually have to pay out of pocket.

” As discussed in Chapter I, the US has over a 30 year history of diverse forms of breast cancer advocacy.
Puerto Rico has a number of small patient support oriented breast cancer advocacy organizations, which
existed prior to the arrival of the Avon Foundation and SGKC. An international affiliate of the American
Cancer Society, which has a breast cancer-speciﬁc campaign, is also active in Puerto Rico. Italy has its own
history of breast cancer advocacy dating back to the early 19805. In addition to a number of patient support
organizations that function in Italy, there is also a strong Europa Donna chapter in Italy. Europa Donna is a
pan-European breast cancer advocacy group that pressures both national European governments and the

73

primarily an intrinsic case study of biomedical breast cancer advocacy organizations,
including these three diverse locations has allowed me to adopt a comparative perspective

as well.

Table 3.1. Comparison of the US, Puerto Rico, and Italy in Relevant Categories

 

 

 

 

 

US US Commonwealth Italy
of Puerto Rico
Geographic North America Caribbean Southern Europe
Region
2007 GDP per 45,800 18,400 30,900
capitall
Relevant US Government Puerto Rican Italian
Governing Bodies Government; US Government;
Government European Union
Healthcare Privatized Government-based National health
system2 healthcare system, healthcare system plan
with limited prior to 1994;
government Health Reform in
assistance 1994 privatized

healthcare, with
limited government
assistance

 

Placement in
WHO Yam“ 5" 37th No data available 2"d
countrres’ quality
of health care
services3

 

Incidence Rate of
Breast Cancer in

O O '2
2000 143 8 63 8 124

(per 100,000)‘

 

 

 

 

 

 

 

European Union to implement standardized best practice guidelines for breast cancer detection, treatment,
and care.

74

Table 3.1 (Continued)

 

 

 

 

 

 

Access to Breast Dependent on health Dependent on health Covered by
Cancer insurance coverage insurance coverage national health
Screening” and ability to pay and ability to pay plan for all
women
between ages
50-69; prior to
age 50 and
after age 69
dependent on
ability to pay
Existing breast Variety of types of Few small, local Transnational
cancer advocacy6 breast cancer breast cancer European
advocacy; well advocacy advocacy
established organizations; network; well
International established;
Affiliate American medical
Cancer Society professionals
involved in
advocacy

 

Sources: 1. Available at https:l/www.cia.gov/library/publications/the-worId-factbook/geos/.htmI.
2. Pan American Health Organization (2007), available at
http://www.paho.org/hia/archivosvolZ/paisesing/Puerto%20Rico%20English.pdf; Giorgi et al. (2007)
3. WHO Health Report (2000)

4. Globocan (2002)
5. Giorgi et al. (2007)

6. Interviews and documentary analysis

ENTRY INTO THE

FIELD

My research is largely based on data collected during two trips to Italy and the US

 

Commonwealth of Puerto Rico, as well as data collected in Lansing, MI. I made my ﬁrst
trip to Italy in September 2007, followed by my ﬁrst trip to Puerto Rico in October 2007.
I strategically planned my trips around SGKC and Avon Foundation-sponsored events so
that I could conduct interviews as well as engage in participant observation at events. The
primary purpose of the 2007 trips was to gather ﬁrst-hand information that would help
me clarify my research questions and research proposal and to develop a feasible research

design. Prior to these trips, I had corresponded with a number of biomedical breast cancer

75

advocates aﬂiliated with SGKC and the Avon Foundation in each location who were very
helpful and agreed to meet with me during my visit. I also used these initial trips to begin
to collect documents and statistics on or related to the expansion of biomedical breast
cancer advocacy to Puerto Rico and Italy.

During the ﬁrst research trip to Italy in 2007, I was primarily based in Rome
since this was where SGKC and Avon Foundation offices were located, making it
convenient to conduct interviews (see Figure 3.2). Rome was also the location where I
collected The Metro, a free widely available newspaper, on a daily basis for the content

analysis component of my research.

Figure 3. 2. Map of SGKC and Avons Foundation Ofﬁce and Event Locations In Italy"
a
HUNGABY»

  
    

1
.IO'IBH Sea

 

 

Porto 't '4’

F0“ enemymbepggio di Calabrla

Meduscmnea: bee L \SW

Catania
usta
Geld‘ > 9

”Wk 0 100 zoom 35‘

wants
~ m r 1 "II

 

Source: www.ceri.org
" Note: While I never visited Milan, it is on the map as the location of Avon Foundation “Walk around the
World for Breast Cancer” events in Italy.

76

I conducted participant observation in Rome, in terms of experiencing the day-to-day
operations of the SGKC ofﬁce; however, the majority of the participant observation took
place north of Rome, in Bologna, for the Race for the Cure events. In 2007, Komen Italia,
the Italian afﬁliate of SGKC, decided to expand their events to northern and southern
Italy, in Bologna and Bari, respectively (see Figure 3.2). Due to the timing of my visit, I
was able to participate in the initial Bologna RFTC event. I participated in the preparation
for the event, Villaggio della Prevenzione (Prevention Village), the volunteer gathering
that evening, and then the RFTC the following day. During these events, I met a
volunteer from Rome who offered to let me stay with her family for the rest of my visit.
This was wonderful, as she was not one of my interview participants, but knew a great
deal about the formation of SGKC in Italy. She was a US expatriate who had married an
Italian and had lived in Rome for many years, so she had experience with SGKC in the
US and was involved with Komen Italia from its inception. Her mother had breast cancer
at the time of my visit, which led us to discuss our experiences dealing with a mother
with breast cancer and made our relationship more intimate than might usually be the
case during research. When I returned from my visit to Rome, before leaving for Puerto
Rico, I conducted four telephone interviews with people who I was unable to meet with
during my visit.

I ﬁrst visited Puerto Rico in October 2007, shortly after my visit to Italy. I stayed
with family members in San Juan, Puerto Rico, who lived within walking distance from
the SGKC Puerto Rico Affiliate ofﬁce (see Figure 3.3). I was able to conduct interviews
in San Juan with members of SGKC as well as with Avon representatives. I found

research in Puerto Rico a little more difﬁcult than in Italy. Most people would not return

77

my calls or e-mails. I would therefore have to physically stop by without a scheduled
appointment and meet people face-to-face in order for them to meet with me. Then I
usually had to make an appointment and return at a later time or date.

I also found Puerto Rican advocates to be more hesitant about participating in my
research. Further, I had trouble communicating with some participants about the purpose
and content of my research project, particularly via e-mail and phone conversations prior
to meeting them in person. I found that because my research focus is breast cancer,
people often thought I was a medical student or a medical doctor, and did not understand
why I would be conducting sociological research on the disease. I also had some trouble
with participant observation in Puerto Rico. After my ﬁrst visit in 2007, I had developed
relationships with key informants. Upon my return in 2008, one of my participants drove
me to an Avon event in Yauco, PR (see Figure 3.3). I found that I was quite conspicuous
among the crowd, given that I was asking lots of questions, taking pictures, and
collecting pamphlets and other written information. At one point, a man working at one
of the informational tables at the day’s events called me over to ask me what I was doing
there. He seemed very skeptical at ﬁrst, especially when I said I was a student doing
research and was there from Michigan. We began speaking in Spanish and then he shifted
to English. He asked about my research, why I choose to come to Puerto Rico to study,
and for whom I worked. After talking for about ten minutes, he asked me my surname
and when I told him, he recognized it and began asking about members of my family who
still live in Puerto Rico. The tone of the conversation completely changed at that point,
and he said “Why didn’t you tell me that you are Puerto Rican?” He then informed me

that he was the president of a large medical association in Puerto Rico and helped me

78

contact other participants for my research. From that point on, research in Puerto Rico
became much easier.

None of the Puerto Rican participants told me why they were initially
uncomfortable with me or my research project. I spoke about this issue with a colleague
who is from the US as well, does not have a Puerto Rican background, and conducted
research on the politics of language in Puerto Rico. She had a similar experience, in that
participants only opened up to her once she informed them that she was engaged to a
Puerto Rican man and would be moving to Puerto Rico permanently once her research
was completed. Based on our similar experiences and some articles I had previously read
on medical research conducted by US doctors in Puerto Rico between the 19408 and 605,
I pursued this issue further to better understand my experience. Puerto Rico has a colonial
history, ﬁrst as a colony of Spain and then as a colony of the US. Currently, Puerto Rico
remains in a state of limbo regarding its sovereignty, as a territory of the US. Between the
19405 and 1960s social scientists used Puerto Rico as a “social laboratory,” viewing it as
an easily accessible Third World country (Lapp 1995). At the same time, medical doctors
from the US promoted sterilization among married Puerto Rican women and tried to alter
the reproductive practices of Puerto Ricans by encouraging reduced fertility (Trombley
1988). Given this history with US social science and medical researchers, it is not
surprising that participants questioned my motivation for researching breast cancer
advocacy in Puerto Rico or that once I disclosed my Puerto Rican family history they
became more comfortable with my interest in conducting research there.

Despite the initial problems in Puerto Rico, my research experience was

overwhelmingly positive. Almost everyone I contacted was willing to meet with me and

79

the majority of participants were extremely helpful and generally forthcoming, although I
found that the higher up a person was in an organization, the less forthcoming he or she
seemed to be. This did not appear to be an attempt to withhold information from me;
rather it seemed that the more established participants had stock answers regarding the
expansion of their organizations that they reported often to the media or via their
websites. Other participants, who were not as embedded in the organizations, seemed to
spend more time thinking about my questions and then responding. The main challenge
that I faced, as mentioned above, was arranging interviews with breast cancer advocates
in Puerto Rico during my ﬁrst visit in 2007. Additionally, due to the limited amount of
time that I was able to spend in each location, primarily due to ﬁnancial constraints, I had
to settle for phone interviews in instances where, due to scheduling conﬂicts, I was not

able to meet with certain people during my visits.

Figure 3.3. Map of SGKC and Avon Foundation Ofﬁce and Event Locations in Puerto
Rico“
PUERTO RICO ‘

Mayague

I i. Penuelas '

    

Source: www.puertorico.eu
" Note: While I did not visit all of the locations marked on the map, the pink dots
represent locations where Avon Foundation “Walk around the World for Breast Cancer”
events were held. SGKC events were held primarily in San Juan. Clockwise, starting at

80

the northeastern part of the island, the locations are San Juan, Caguas, Penuelas, Yauco,
Mayagr’iez and Arecibo.

Another challenge that I confronted during this research is that because I am
studying an expansion process that is occurring right now, getting up-to-date information
has been challenging. When I ﬁrst proposed doing this research, SGKC only had three
international afﬁliates. Over the course of the last year, however, they have expanded to
ten additional international locations, establishing global initiative pilot programs, which
are distinct from affiliates in that they do not take on the name of Susan G. Komen for the
Cure, but involve local advocates, medical professionals, and other interested groups who
are trained in Susan G. Komen for the Cure fundraising and awareness-raising advocacy
techniques. Similarly, Avon’s programs and events also have evolved over the two-year
period of time that I have been following the expansion process. Even visiting two
locations just a year apart, there was some tum-over in terms of advocates and the new
advocates often did not know as much about the development of the afﬁliates as had the

earlier advocates.

QUALITATIVE RESEARCH METHODS

Scientiﬁc objectivity has traditionally assumed that researchers can have “inﬁnite
vision,” or what Haraway (2004, 128) calls the “god trick.” On the other hand, relativist
accounts are equally problematic since it “is a way of being nowhere while claiming to be
everywhere equally” (Haraway 2004, 129). Rather, all research accounts are based on
knowledge that is situated and embodied and the struggle is always over whose view of
the world should count as rational (Haraway 2004, 130). Harding’s (2004, 136) concept

of ‘strong objectivity’ requires that we question the notion of independence in science

81

and instead demand methods that allow us to examine the range of social values and
situations that shape the research process. To accomplish this, it is necessary to include
the perspectives of those actors who are generally marginalized from the scientiﬁc
process. Nevertheless, while recognizing the social situatedness of all knowledge, strong
objectivity requires from researchers “a critical evaluation to determine which social
situations tend to generate the most objective knowledge claims” (Harding 2004, 134).

A qualitative research approach is useful for accomplishing these objectives. In
particular, qualitative research is valued for its commitment to viewing the social world
from the perspective of participants involved in the phenomenon being studied (Blaikie
2000). Qualitative methods provide a means to understand the social, political and
economic situation of participants. Situation is important because it inﬂuences how
people understand particular events or actions and how they act in relation to them.
Additionally, it provides a way to incorporate meaning, that is, how participants — as well
as the researcher — understand, view, or interpret the situation of participants, the
situation of those around them, and the effects of particular events on their circumstances.
This approach also allows researchers to describe the processes through which particular
events or actions take place.

For this study, I have utilized several qualitative data-collection techniques
including semi-structured interviewing, participant observation, and content analysis, that
have allowed me to build a holistic, multi-dimensional, complex account of the answers
to my research questions. By incorporating the voices of participants who are involved in
and, therefore, proponents of SGKC’s and Avon Foundation’s global expansion together

with alternative sources of data from government documents, members of breast cancer

82

organizations that are unaffiliated with SGKC and Avon Foundation, and international
representatives from the Global Advocate Summit, 1 seek to arrive at a more inclusive
and comprehensive understanding of the global expansion of biomedical breast cancer
advocacy.

It is reasonable to wonder what value, if any, does this case study involving a
small number of individuals primarily representing two organizations that address a
speciﬁc health issue have beyond this particular case. It is generally accepted that in
contrast to quantitative studies, it is not possible to generalize qualitative research results
to the general population (Babbie 2004). Nevertheless, there is a growing concern with
the issue of generalizability and how it might be achieved, as researchers become
interested in making statements about other sites or populations based on their own
research results (Blaikie 2000).

Rather than generalizability, some scholars emphasize concepts such as
‘transferability’ or ‘comparability’ (Goetz and LeCompte 1984 cited in Blaikie 2000,
255). The argument here is that study results can be extended to other cases on the basis
of theory development and by using comparable data collection methods and analyses
across research sites. On this basis, “similarities and differences can then be taken into
account in any judgment about the relevance of ﬁndings obtained from one site for some
other sites” (Blaikie 2000, 253). The aim in such comparisons is generally “to establish
whether the research site is typical of other sites” (Blaikie 2000, 255). Researchers
conducting studies about the global expansion of breast cancer advocacy in other sites as

the coalition continues to expand, who incorporate similar theoretical frames and

83

methodological techniques, should be able to make comparisons between this study and

research sites with their own.

DATA COLLECTION AND ANALYSIS

As stated above, in order to answer my research questions, I utilized three
qualitative research techniques: (1) semi-structured interviews; (2) qualitative content
analysis of SGKC, BHGI, and Avon Foundation documents, newspaper articles,
government documents, and corporate sponsor documents, and global health documents

and statistics; and (3) participant observation. '2

Interviews
Interviews have been shown to be effective in gaining nuanced information on values,

perceptions, and motivations behind actions. My overarching goal with the interviews
was to identify how and why biomedical breast cancer advocacy organizations are
expanding globally. That is, why did people working within SGKC and the Avon
Foundation decide to expand beyond the US, how was the decision to expand made, and
how were the expansion locations selected? How did SGKC and Avon Foundation
advocates in Puerto Rico and Italy incorporate biomedical breast cancer advocacy into
their distinct cultural and political contexts? How were local breast cancer organizations
in Puerto Rico and Italy, not afﬁliated with SGKC or Avon Foundation, affected by the
expansion of SGKC and Avon Foundation? And how did international breast cancer
advocates, who attended the 2007 Global Advocate Summit in Budapest, Hungary,

perceive the global expansion of SGKC and the Avon Foundation?

 

'2 This research protocol was approved by Michigan State University’s Institutional Review Board, [RB
#07-836 on August 24, 2007.

84

I made no attempt to obtain a random sample of interviewees; rather, the sample
was purposive (Berg 2004). Participants were seen as key informants and the intent of the
interviews was to ensure organizational representativeness and maximize variation in
responses so as to obtain as complete an understanding as possible of the informant’s
views of issues related to the global expansion of biomedical breast cancer advocacy
(Berg 2004; Creswell 1999; Maxwell 1998). I began the interview process by identifying
several key informants within SGKC in the US, the Avon Foundation in the US, SGKC
and Avon Foundation affiliates in Puerto Rico and Italy, and the BHGI in the US. Names
of informants came from the organizations’ websites and publications. I expanded my
informant pool using the snowball technique where participants were asked to
recommend other key actors for me to interview (Berg 2004, 36). I stopped conducting
interviews once I reached a saturation point, at which time I was receiving information
that I had already heard from other interviewees (Berg 2004).

I utilized snowball sampling (Berg 2004) by asking those whom I interviewed for
names of other organizations that are relevant to global breast cancer advocacy or to
breast cancer advocacy in the context in which they are working (e. g., other breast cancer
organizations in Puerto Rico or Italy). Through snowball sampling, I developed a better
understanding of global breast cancer advocacy coalitions and interviewed breast cancer
advocates from organizations such as the BHGI, Europa Donna (the European Breast
Cancer Coalition), and Mujeres sin Tiempo (a Puerto Rico-based, breast cancer advocacy
group). Europa Donna is an international non-governmental organization (INGO)
operating throughout Europe that consists of a membership that is aware of, but not

associated with, SGKC and the Avon Foundation. Mujeres sin T tempo (Women without

85

Time) is an organization that works exclusively in Puerto Rico dealing with breast
cancer, and it also is not affiliated with SGKC or Avon Foundation programs. By
including interviews with actors such as these who are not directly involved in the global
expansion of biomedical breast cancer advocacy, but may affect and/or be affected by
this type of advocacy expansion, I sought to add additional perspectives to my

understanding of the global expansion of biomedical breast cancer advocacy.

The result was that semi-structured, on-site and telephone interviews were
conducted with a total of 24 participants (see Figure 3.4). It is important to note that
while I have categorized each participant according to his or her primary organizational
affiliation or conference attendance; some participants could have been included in more
than one category. For example, some of the key informants from SGKC and the BHGI
who I interviewed were also organizers of and participants in the Global Breast Cancer
Advocate Summit (GBCAS). In these cases, I categorized participants according to their

main role in relation to our interview.

Participants included key decision-makers in SGKC and the Avon Foundation
who speciﬁcally worked with the global initiatives within their organization, leaders of
the BHGI, leaders within Komen Puerto Rico and Komen Italia, leaders within local
breast cancer organizations who were not affiliated with SGKC or the Avon Foundation,

and international delegates who attended the 2007 Global Advocate Summit in Budapest.

86

Figure 3.4. Categories and number of participants involved in formal interviews"

 

Waflnbrvlm

O-INw-hOIONQGD

 

SGKC AF BHGI GBCAS LBCO
Categories of Interview Participants

 

 

 

Source: Personal and Telephone Interviews
’AF refers to the Avon Foundation. GBCAS refers to the Global Breast Cancer Advocate
Summit. LBCO refers to local breast cancer organizations.

All of the interviews were conducted in English. Sixteen interviews were
conducted in person, and eight interviews were conducted over the phone, due to an
inability to meet with the person. For personal interviews, I met the participants wherever
they preferred to be interviewed. In most cases, the interviews were conducted in their
organization’s office. A couple of interviews were conducted outside in a public park
setting at a RFTC event or an Avon Foundation event. For the telephone interviews, I
talked to the participants while they were at work at their organization’s ofﬁce. I
conducted the phone interviews from home using an earpiece recording device, once I
had received informed consent to record via fax or mail from the participants.

I audio taped all of the interviews to ensure accuracy. The majority of the
interviews lasted between forty-ﬁve minutes and one hour. Prior to each interview, I
explained to participants the prupose of my research, that their participation was entirely

voluntary and that they could halt or withdraw from the interview at any time, and that

87

their responses would remain conﬁdential. To this end, pseudonyms have been given to
all participants. All interviewees signed an informed consent form in which they agreed
to the interview and separately agreed or refused to be tape-recorded (see Appendix). All
of my participants agreed to have the interview tape-recorded.

The interview guides can be found in Appendix II. While the focus of the
interview questions was in relation to the participants’ perceptions, practices, and
involvement with the global expansion of biomedical breast cancer advocacy, these
questions varied to accommodate the affiliation of the different participants (e. g., SGKC,
Avon Foundation, BHGI, LBCO). Moreover, the interview questions in my guide were
not ﬁxed but continued to evolve over time as I determined that it was necessary to
explore some questions in more depth or add new questions altogether, this was the case
because I conducted interviews over a two-year period, in 2007 and 2008.

I designed the interview questions to address how and why biomedical breast
cancer advocacy organizations are expanding, how and why particular countries were
chosen for expansion, which forms of advocacy (e.g., “racing for the cure,” “breast
cancer awareness mon ”) have been incorporated into, and possibly adapted to, other
political and cultural contexts, how the pink ribbon has been incorporated into, and
possibly adapted to, other political and cultural contexts, and the role corporate
sponsors/partners play in movement expansion.

I transcribed all of the interviews myself. They were transcribed verbatim. Then I
entered all interview data into Atlas.ti (a software program for qualitative data analysis)
and analyzed them. The purpose of the analysis was to develop an understanding of why

and how biomedical breast cancer advocacy organizations have expanded globally, how

88

various organizations are involved, how the choice of countries to expand to was made,
and how forms of advocacy, movement symbols, and corporate involvements have been
adapted to, if at all, diverse political and cultural contexts.

I began the coding process by conducting line-by-line open coding of all of my
interviews (Berg 2004). Next, I thematically organized the codes that emerged from the
open coding process. The codes that I developed were drawn from my conceptual
framework, my research questions, as well as inductively generated from the research
process. Categorizing the data in this manner made it easier to organize the data, to
identify major themes that emerged from the interviews, and to compare the views of

different participants in light of my research questions (Maxwell 1998; Strauss 1998).

Qualitative Content Analysis
My research is also based on the analysis of an extensive collection of documents and

statistics covering the years 1998 to 2008. These materials include SGKC, Avon
Foundation, and BHGI primary documents related to the global expansion of biomedical
breast cancer advocacy, such as annual reports, publications, conference agendas and
reports, informational packets on how to train global advocates, materials used to educate
the public about breast cancer and press releases from 1998, when the earliest documents
addressing the global expansion of biomedical breast cancer advocacy began appearing,
to 2008. Organizational documents were collected via organizational websites, visits to
the organization’s ofﬁces, personal communications in which informants offered to send
me information, and GuideStar, Inc., an online database of nongovernmental
organizations. Additionally, I collected primary documents from the pharmaceutical and

corporate sponsors of SGKC, Avon Foundation and the BHGI that are involved with

89

these organizations outside of the US, Puerto Rican, Italian, and US government
documents, NIH and WHO reports, scholarly publications, and Globocan statistics
related to the global burden of breast cancer. Data about breast cancer as compared to
other chronic and infectious diseases were also collected. Finally, newspaper articles and
advertisements related to breast cancer advocacy, incidence, and/or organizations from El
Nueva Dia, the most prominent daily newspaper in San Juan, PR, and from The Metro, a
free daily newspaper in Rome, Italy were collected during the time that I was in each
location (September/October 2007 and 2008).

According to Berg (2004, 269), qualitative content analysis is “a passport to
listening to the words of the text and understanding better the perspective(s) of the
producer of these words.” These materials were particularly valuable in expanding my
understanding of the global expansion of biomedical breast cancer advocacy, the manner
in which various organizations are involved, the partnerships between various advocacy
organizations with medical professionals, other organizations, and corporations, the
forms of advocacy that are being promoted globally, the burden of breast cancer on a
global scale compared to other chronic and infectious diseases, and the presentation of
transnational biomedical breast cancer advocacy organizations in local newspapers. I also
used these materials to help clarify, probe, or conﬁrm claims made by participants in the

interviews.

Participant Observation
Participant observation is also an important methodological element of this project. This

method was particularly useful for my research in terms of observing visual symbols and

experiencing how the events actually unfolded and took place in different political and

90

cultural contexts. I was able to produce data through participant observation that did not
emerge in interviews and content analysis. In particular, I was able to experience how the
events vary in different political and cultural contexts. Further, I was able to observe
which corporate sponsors/partners were present at events, what other organizations were
present, the demographics of those who participated, and the various roles of the
participants, including organizers, sponsors, and local participants, in the events.

I conducted participant observation at three Race for the Cure events in Lansing,
MI between 2006 and 2009 in order to improve my ability to recognize similarities and
differences between RF TC events in the US and other countries. I also attended the ﬁrst
RFTC event in Bologna, Italy in October 2007 and returned the following year for the
same event, allowing me to notice any changes in the event from one year to the next. In
addition to the actual RFTC events, I was able to conduct participant observation at
volunteer planning meetings, at the Villagio della Prevenzione, as well as at the volunteer
dinner the night before the race. While attending these events, I was able to observe the
presence and activities of corporate sponsors/partners, medical professionals, SGKC
afﬁliates, and other organizations. I also noted the demographics of the participants, the
number of participants, the emotional tenor of the event, the mood of the participants, and
the cultural, geographic and political context in which the event took place.

I conducted participant observation in Puerto Rico in October of 2007 and 2008
as well. I was unable to attend Race for the Cure events in Puerto Rico, due to an
overlapping schedule between Italy and Puerto Rico events, and thus had to rely on
documentary analysis and interviews with participants in the event for information. In

San Juan, PR, I visited both the SGKC afﬁliate ofﬁce and the Avon Foundation office on

91

numerous occasions, observing the workings of the organizations. I also attended an
Avon-sponsored event, Marcha Por Una Causa in Yauco, PR. At this event, I was able
to observe the presence and activities of corporate sponsors/partners, medical
professionals, Avon representatives, as well as other organizations. I also noted the
demographics of those who participated, and the various roles of the participants,
including organizers, sponsors, and local participants, in the events. Finally, I was able to
get a feel for the event, the emotional tenor of the event, the mood of the participants, and

the cultural, geographic and political context in which the event took place.

CHAPTER SUMMARY
In this chapter I have presented my research design for the case study of the global

expansion of biomedical breast cancer advocacy. I discussed the feminist research
methodology that informs my approach to research. The rationale of the organizations
and speciﬁc locations that I focused on in my research were then addressed. Following
this discussion, I addressed issues related to gaining access to research participants in
each research site. Finally, my rationale for utilizing qualitative methods for answering
my research questions as well as descriptions of my data collection and analysis process

were provided. In the chapters that follow, I discuss the ﬁndings of my research.

92

CHAPTER 4
ELITE ORGANIZATIONS AND GLOBAL EXPANSION

According to Reitan (2007, 16), “while there is growing evidence that activism is in fact
‘going global,’ there have been remarkably few studies to date that empirically
investigate how and why this process is occurring” {e.g., Olesen 2005; della Porta 2005).
In her research on social movements that have mobilized against neoliberal policies,
Reitan (2007) found that localized movements often shift to globalized action via a
similar sequence of action. Movements expanded primarily due to a realization “of the
need to ‘go global’ fueled by frustration in not getting desired results at the local or
national level” (my emphasis, Reitan 2007, 19). Once local movement members
developed this realization, movement organizers would reach across national boundaries
to forge ties with potential allies. According to Reitan (2005), this process often involved
frame alignment efforts, in which movement participants seeking global expansion
extend the framing of their movement to a related issue in order to connect to potential
allies working on similar issues. While Reitan (2005) found that this sequence of action
applies to grassroots movements, I found that alternative explanations are required to
account for the global expansion of elite advocacy organizations.

In this chapter I present my ﬁndings regarding the reasons for Susan G. Komen
for the Cure’s and the Avon Foundation’s global expansion as well as the trajectory of
each organization’s global expansion. In this chapter, I draw primarily on interview and
documentary data. I found that in stark contrast to grassroots, anti-neoliberal
globalization movements’ expansion, which is motivated by a lack of desired results at

the local or national level, leaders of SGKC decided to “go global” precisely because

93

they had achieved their desired results in the US. The Avon Foundation, on the other
hand, globally expanded due to the interests of the Avon Company in expanding its brand
recognition in emerging markets, as Company sales slowed in the US market. SGKC and
the Avon Foundation, despite organizational differences, both “went global” to expand
their brand to new markets. For both organizations, global expansion was the logical
extension of a general pattern of growth and expansion. In the case of SGKC, the leaders
of the organization wanted to expand their successful brand of advocacy and their
reputation as pioneers in breast cancer advocacy. The Avon Company, on the other hand,
expanded the Avon Foundation to locations where the company already operated in order
expand and solidify the market for its beauty products and enhance the Company’s
reputation as the “Company for Women.” Both organizations globally expanded based on
a corporate model of market expansion.

In what follows, I ﬁrst present an overview of the organizational and ﬁnancial
resources of SGKC and the Avon Foundation. I discuss the organizations separately in
this chapter, as they developed independently of each other. I then argue that based on its
organizational and ﬁnancial successes in the US, SGKC expanded globally to extend its
brand of advocacy and reputation as pioneers in breast cancer advocacy based on a
corporate model of continual growth. Under the leadership of the Avon Company, the
Avon Foundation globally expanded to extend the brand recognition of its cosmetic

products and Avon’s reputation as “The Company for Women.”

94

ORGANIZATIONAL AND FINANCIAL RESOURCES

Susan G. Komen for the Cure

In slightly over twenty-ﬁve years since being founded by Nancy Brinker in 1982, Susan
G. Komen for the Cure has grown into the largest breast cancer organization in the world
and the largest non-governmental funder of breast cancer research (King 2006). Despite
SGKC’s claim of being “a global grassroots movement” and Nancy Brinker as
demonstrating “the power of one” and acting as “proof of how personal activism can
drive global social change,” SGKC has elite origins and continues to be an elite-run
advocacy organization that utilizes a corporate model to guide its organizational and
ﬁnancial endeavors (SGKC 2008).

Nancy Brinker’s husband, Norman Brinker, owner of Brinker International, one
of the world’s largest casual dining companies, enabled the development of SGKC by
providing access to capital and inﬂuence (New York Times, 1992).13 Norman Brinker,
acting as Chair of the Board of Directors of SGKC during its early years, provided the
initial funds needed to get SGKC off the ground and applied his business expertise to
building the Foundation (F etterman 2007). Well after SGKC had taken off and become
the leading breast cancer advocacy organization, Norman and Nancy Brinker divorced.
Nevertheless, Norman Brinker remains on the Board of Directors of SGKC, continuing to
offer business advice and access to wealthy supporters and potential partners in the

business world (SGKC 2009).

 

'3 Brinker International is a restaurant group that includes Chili’s Grill & Bar and Romano’s Macaroni
Grill, among others. Norman Brinker established the J ack-In-The-Box chain of restaurants in 1957. He
started Steak and Ale in 1965. He became the president of the Pillsbury Restaurant Group in 1982,
overseeing Steak and Ale, Burger King, and Bennigan’s, to name a few (SGKC 2009).

95

After creating the organization with the ﬁnancial support and input of her
husband, Nancy Brinker launched the Race for the Cure, which has developed into “the
most successful ﬁmdraising and education event for charity ever created” (SGKC 2009).
Additionally, based on her connections in the business world, she “pioneered cause-
related marketing, which has enabled millions more people—from top executives to
everyday consumers—to join the ﬁght against breast cancer” (SGKC 2009).14 To date,
SGKC is the “world’s largest source of nonproﬁt funds” dedicated to biomedical breast
cancer research (SGKC 2009). Based on her connections, Nancy Brinker was able to
implement her vision of an advocacy organization that enlists “every segment of society
to participate in the elimination of the disease,” in a way that less well-connected
advocacy organizations would be hard-pressed to do (SGKC 2009).

In addition to her business background and her husband’s corporate connections,
Nancy Brinker, and SGKC by proxy, has enjoyed a favorable relationship with the US
government, especially during George W. Bush’s tenure in the White House.” Nancy
Brinker was a member of the National Cancer Panel under Presidents Reagan and H.W.
Bush, served as US Ambassador to the Republic of Hungary from 2001 through 2003
under President George W. Bush, and was appointed Chief of Protocol of the United
States, with the rank of Ambassador and Assistant Under-Secretary of State in 2007,
which lasted until the end of Bush’s term (SGKC 2007). These government positions

directly impacted the global expansion of SGKC, allowing Nancy Brinker to initiate

 

1’ Prior to founding SGKC, Nancy Brinker had a successful career in business and marketing, working with
such companies as ManPower, Inc., United Rentals, Inc., US Oncology, Inc, Netrnarket, Inc., and Meditrust
Corporation. She also started a health and wellness products business, which she later sold (JournalStar
1999)

'5 Nancy and Norman Brinker contributed to George W. Bush’s first presidential campaign and Norman
Brinker has a long history of ﬁnancially backing Republican presidential candidates (Government 2009).

96

collaborative programs between SGKC and the US State Department to expand SGKC
internationally as an act of governmental diplomacy.

Nancy Brinker also has had a long-term friendship with Laura Bush, who has
dedicated herself to the breast cancer cause due to her mother’s experience with the
disease. As First Lady, Laura Bush used her position to further SGKC’s global
expansion, acting as Honorary Co-Chair of SGKC’s Global Advocate Summit in
Budapest, Hungary in 2007. Additionally, she has visited international SGKC affiliates,
such as Komen Italia, commending them on the work that they are doing to eradicate
breast cancer (SGKC 2006). She has also supported and participated in the US
partnerships in the Middle East and Central and South America to raise breast cancer
awareness. Encouraging other Presidents’ and Prime Ministers’ wives to take up the
breast cancer cause, Laura Bush has spoken on behalf of SGKC in many countries
(Figure 4.1). In addition to the involvement of former First Lady Laura Bush, US
Ambassadors in countries where SGKC is active often attend events on behalf of the
United States. Having US governmental representatives promoting SGKC on an
international level, presents the organization to international audiences as simultaneously

an advocacy organization and a governmental diplomatic initiative.

97

Figure 4.1. Laura Bush speaking to Komen Italia advocates on behalf of the US
ovemment and SGKC

    

Source: Press Release, Office of the First Lady, February 6, 2006

In addition to Nancy Brinker’s governmental connections, the organization is
headed by an elite board of directors and run by a professional staff in Dallas, TX, with
two prominent business and marketing ﬁgures, Susan Braun (1996-2006) and Hala
Moddelmog (2006-present) acting as President and CEO of the organization after Nancy
Brinker.'6' ‘7 The board of directors governs the organization’s efforts to support breast
cancer research and community education, screening and treatment programs. It is a nine-
member board whose members have extensive business and non-proﬁt experience (Table
4.1) (SGKC 2009). The board consists of a number of breast cancer survivors, all with

extensive business and/or voluntary non-profit experience as well (Table 4.1).

 

'6 During her tenure as President and CEO of SGKC, Susan Braun simultaneously served on leadership
committees for the National Action Plan on Breast Cancer, the American Society of Clinical Oncology
(ASCO), the Cancer Leadership Council, and the Would Society of Mastology. Prior to joining SGKC, she
worked within the Oncology/Immunology Division of the Bristol-Myers Squibb Company. She also
worked as an executive with the healthcare consulting ﬁrm, Pracon Inc. Her graduate educational
background is in international marketing (Zoomlnfo 2008)

7 Prior tojoining, SGKC, Hala Moddelmog was a Fortune 500 executive, sewing as the founder and CEO
of Catalytic Ventures, a company she founded to consult and invest in the food service industry. She was
president of Church’s Chicken. Prior to that, she held management and marketing positions at Church’s
Chicken, Arby’s Franchise and BellSouth (Reuters 2008).

98

Table 4.1. SGKC’s Board of Directors (2009)

 

Name/Position

Breast Cancer
Survivor

Occupational History (Position/Sector)

 

Alexine Clement
J ackson/Chairperson

Yes

YWCA of USA (National Board Chair/Non-Proﬁt);
Intercultural Cancer Council (Board Member/Non-
Proﬁt); Black Women’s Agenda (Board
Member/Non-Proﬁt)

 

Nancy Brinker/Board
Member and Past
President and CEO

Yes

ManPower Inc. (Director/Employment Services);
United Rentals (Director/Rental Equipment); US
Oncology Inc.(Director/I-lealthcare Services);
NetMarket Inc. (Director/Internet Product Provider;
Meditrust Corporation (Director/I-Iealthcare Real
Estate Investrnant Trust); US Government
(Ambassador to Hungary/Govemment); US
Government (US Chief of Protocol/Govemment)

 

Norman Brinker/Board
Member and Chairman
Emeritus

No

Brinker lntemational (Chairman
Emeritus/Restaurant); Jack-in-the-Box
(Founder/Restaurant); Steak and Ale
(Founder/Restaurant); Pillsbury Restaurant Group
(President/Restaurant)

 

Linda Custard/Board
Member

No

Junior League of Dallas (President/Non-Proﬁt);
United Way of Dallas (Vice Chair/Non-Proﬁt);
Dallas Women’s Club (President/Social Club);
Southern Methodist University
(Trustee/University); Dallas Center for the
Performigg Arts Foundation (Director/Non-Proﬁt)

 

Aimee DiCicco/Board
Member

Yes

FedEx Kinko’s (Vice President of Sales/Service)

 

Brenda Lauderback/
Board Member

Yes

Nine West Group (President of Wholesale and
Retail/Clothing); Irwin Financial Corp. (Corporate
Director of the Board/Financial); Big Lots
Corp.(Corporate Director of the Board/Furniture)
Select Comfort (Corporate Director of the
Board/Bedding); Denny’s (Corporate Director of
the Board/Food)

 

Connie O’Neill/Board
Member

No

Susan G. Komen for the Cure (Past Treasurer/Non-
Proﬁt); Children’s Medical Center Foundation
(Board Member/Non-Proﬁt); Children’s Health
Services of Texas (Chair of Audit
Committee/Govemment); Highland Park Education
Foundation (Past President/Non-Profrt); St. Paul
Medical Center Foundation (Board Member/Non-
Proﬁt);

 

Robert Taylor/Board
Member

No

Taylor Lohmeyer Law Firm (President/Legal
Services); Dallas/Ft. Worth Duke University
Alumni Admissions Committee
(Chairman/Education); Highland Park United
Methodist Church Board of Trustees (Past
Chairman/Religious)

 

 

Dorothy
Paterson/Afﬁliate
Representative and
lntemational Race
Ambassador

 

Yes

 

Oil business (Geologist); MD Anderson Cancer
Research Center (Volunteer/Medical Research);
Girl Scouts of American (Volunteer/Non-Proﬁt)

 

Source: SGKC “Board of Directors” (2009)

99

 

In addition to the board of directors, the organization has a seven-person scientiﬁc

advisory committee, which consists of M.D.s and Ph.D.s from prominent universities and

cancer research centers (Table 4.2) (SGKC 2009). The Scientiﬁc Advisory Board guides

the organization in scientiﬁc matters, making recommendations regarding the funding of

medical research and the development of educational messages (SGKC 2009).

Table 4.2. SGKC’s Scientiﬁc Advisory Board Members (2009)

 

 

 

Name Position Affiliation

Eric Winer, MD. Chief Scientiﬁc Advisor for Dana-Farber Cancer Institute;
SGKC; Director of the Breast Harvard Medical School
Oncology Center; Senior
Investigator in Breast Cancer
Research

Melissa Bondy, PhD. Professor of Epidemiology- University of Texas MD.

specializing in the study of
genetics and risk factors which
cause cancer

Anderson Cancer Center

 

Powel Brown, Ph.D.

Professor of Medicine; Associate
Director of Cancer Prevention and
Director of Cancer Prevention and
Populations Study Proggam

Baylor College of Medicine; Dan
L. Duncan Cancer Center; Breast
Care Center Baylor-Methodist

 

H. Kim Lyerly, MD.

Professor of Research; Director of
the Duke Comprehensive Cancer
Center; Principal Investigator of
the Duke Specialized Program in
Research Excellence

Duke University

 

Amelie Ramirez, M.D.

Chairman of Komen’s National
Hispanic/Latino Advisory Council;
Professor of Epidemiology and
Biostatistics; Founding Director of
the Institute for Health Promotion
Research

University of Texas Health
Science Center at San Antonio;
formerly afﬁliated with the
National Cancer Advisory Board

 

George Sledge, MD.

Professor of Oncology, Medicine,
and Pathology; Co-director of
Breast Cancer Program

Indiana University Melvin and
Bren Simon Cancer Center;
Indiana University School of
Medicine

 

Sara Sukumar, Ph.D.

 

 

Professor of Oncology and
Pathology; Co-director of the
Breast Cancer Research Program

 

Sidney Kimmel Cancer Center at
Johns Hopkins University School
of Medicine

 

 

Source: SGKC “Scientific Advisory Board” (2009)

Specialist advisory councils organized around issues faced by African American

women, Hispanic and Latina women, Asian American and Paciﬁc Islander women,

young women, and lesbian, gay, bisexual and trarrsgender persons are also part of the

organization. These advisory councils are made up of public health specialists and

100

01

educators, M.D.s, RNs, and Ph.D.s specializing in particular demographics of women and
breast cancer (SGKC 2009). Finally, local and international affiliates are constituted by
survivors and activists in more than 120 cities and communities across the globe, which
according to Brinker, she developed based on “the Chili’s Restaurant business model,
used by her husband, Norman Brinker,” exemplifying the organization’s corporate
business model for organizational expansion (F etterman 2007).

Aided by Norman Brinker’s successful business model and corporate connections,
SGKC has been an incredibly ﬁnancially successful organization. This success is largely
attributable to partnerships with over 170 corporations (SGKC 2008). Partnering
corporations directly sponsor events and engage in cause-related marketing campaigns
(King 2006).18 In an interview with The Dallas Morning News, discussing the
organization’s 25 years of work fundraising for breast cancer research, Brinker stated, “I
can’t tell you how many people said it wouldn’t work, marketing a women’s disease”
(my emphasis, Fettennan 2007). This statement demonstrates the business model applied
to breast cancer advocacy by the organization. Despite any skepticism, SGKC has
successfully marketed breast cancer in the US, acquiring an unprecedented and to date an
unmatched number of corporate partners that are marketing a disease-related cause. In
Table 4.3, SGKC’s corporate sponsors are listed according to SGKC’s categorization of

the partnerships.

 

'8 More than one hundred Komen Race for the Cure events, consisting of over one million participants,
were held in the US and internationally in 2008 {SGKC, 2009 #414}

101

Table 4.3. SGKC’s Categorization of Corporate Sponsors and Partners

 

Komen Million Dollar Acushnet-Titleist, Cobra and FootJoy Worldwide, American
Council" Airlines, Bank of America, Better Homes and Gardens, Carlisle
Collection Ltd, Coldwater Creek, Ford Division, General Mills’
Pink Together, Hallmark Gold Crown Stores, Holland America
Lines, KitchenAid, Lean Cuisine, Lowe’s Companies Inc, Mars
Snackfood US LLC, New Balance Athletic Shoe Inc., Pier 1
Imports, Rally for the Cure, REMAX lntemational, The Bowling
Foundation, The Mohawk Group, Wacoal America, Yoplait USA

 

Corporate Partners 3M, ACH Food Companies Inc., Acushnet, American Airlines,
Atlas Garden Glove, Bank of America, Belk, Belkin, Best Buy and
Virgin Mobile, Better Homes and Garden, BMW of North
America, Brinker lntemational, Carlisle Collection Ltd, Carnival
Cruise Lines, Coldwater Creek, Don King Productions, Dr. Pepper
Snapple Group, Energizer, Ford Division, Fox Home
Entertainment, Fresh Express, FUZE Beverage, General Mills’
Pink Together, Grand Traverse Pie Company, Hallmark Gold
Crown Stores, Holland America Line, HSN, Kentucky Oaks Ladies
First, KitchenAid, Ladies Professional Golf Association (LPGA),
LEAN CUISINE, LIFE Event-The Val Skinner Foundation,
LifeWorks Technology Group, Lowe’s Companies Inc., LPGA
Golf Clinics, Major League Baseball, Mars Snackfood LLC,
Massage Envy, McNeil Nutritionals LLC-Viactiv, Microsoft,
MMG Corporation, Mobile Giving, Mott’s, NAPA AutoCare, New
Balance Athletic Shoe Inc., North American Licensing, On Deck
for the Cure, On the Border-Fiesta for the Cure, Oreck, Pandora
Jewelry, Paramount Coffee, Payless ShoeSource, Pier 1 Imports,
PiNKiTUDE, Pottinger Nichols Media Group LLC, Princess
Cruises, Quilted Northern Ultra, Rally for the Cure, REMAX
lntemational, Simon Malls, Specialized Bicycle Components, The
Bowling Foundation, The Mohawk Group, The Republic of Tea,
Tubbs Romp to Stomp Out Breast Cancer Series, Wacoal America,
Wyeth-Chapstick Brand Lip Moisturizer, Yoplait USA, Zale
Corporation, Zeta Tau Alpha Fraternity

 

Race for the Cure National Yoplait USA, American Airlines, Bank of America, Coldwater
Sponsors Creek, Ford Division, FUZE Beverage, Mott’s, New Balance
Athletic Shoe Inc., REMAX lntemational, Zeta Tau Alpha
Fraternity

 

 

 

 

Source: http://ww5.komen.org/milliondollarcouncilaspx; http://wwS.komen.org/corporatepartrrers.aspx;
http://wwS.komen.org/raceforthecuresponsors.aspx

’The Komen Million Dollar Council Elite is a special group of sponsors and partners who have committed
to invest a financial contribution of $1 million annually in the ﬁght to end breast cancer. Each of these
organizations has found new and innovative ways to raise awareness about breast cancer and encourage
people from all walks of life to get involved in ﬁnding the cures. We thank them for their generous support
(SGKC 2009).

These partners raise signiﬁcant funds for SGKC by engaging in cause-related marketing
campaigns in which they sell pink products, donating a certain percentage of the sales to
SGKC for breast cancer research. For example, from every sale of a $350 pink mixer,

KitchenAid donates $50 to SGKC (Figure 4.2).

102

Figure 4.2. KitchenAid’s Cause-Related Marketing Mixer“

(00k
(UH!
-

 

 

 

 

 

Source: http://www.kitchenaid.com/ﬂash.cmd?/#/product/KSM1SOPSPK/

I'The text in the advertisement reads, Cook for the Cure presented by KitchenAid. Susan G. Komen for the
Cure. During 2008, KitchenAid is proud to donate a minimum of $100,000 to Susan G. Komen for the
Cure in conjunction with its pink product collection. Consumers must register each pink product purchased
at CookfortheCure.com to generate a donation.

Through fundraising events and cause-related marketing campaigns, SGKC has become a
ﬁnancially lucrative organization. According to SGKC’s 2004-2005 Annual Report,

In ﬁscal year 1995, the Komen Foundation invested $10.1 million in the ﬁght
against breast cancer. Ten years later, in ﬁscal year 2005, the Foundation invested
135.8 million. This growth has allowed us to further our mission by advancing
research, education, and screening and treatment worldwide. And while our
growth over the past ten years has been signiﬁcant, we are committed to ensuring
this momentum continues, pushing us forward, searching for answers, putting our
promise in action (my emphasis, SGKC 2006)

SGKC’s ﬁnancial resources continue to grow each year. The majority of funds are
allocated for breast cancer research and education programs, followed by screening and

treatment (see Figure 4.3).

103

o- i
era 13%

.{y'

A
a..." M I

Source: Susan G. Komen for the Cure 2008 Annual Report (SGKC 2008)

 

Based on a corporate business model, ever since its inception SGKC has grown,
increasing its number of affiliates, corporate partnerships, and Race for the Cure events.
Currently, the organization is well-known throughout the US, with at least one afﬁliate in
every state, and multiple afﬁliates in a number of states. Based on the logic of expansion,
and the organization’s tremendous organizational and ﬁnancial success in the US, having
captured the US breast cancer advocacy market, it is not surprising that SGKC began
looking beyond the US for future expansion opportunities in the late 1990s.

Avon Foundation
The Avon Company established the Avon Foundation in 1955. With the slogan “The

Company for Women,” Avon executives decided that having an afﬁliated Foundation

104

CHIC

(It

can

TV

JJIVI

addressing issues affecting women would support the tagline and help the Company build
a unique reputation as a “women’s company” (Avon 2005). Deciding to narrow the focus
of the Foundation, Company executives chose two women’s issues that it would work on,
namely, breast cancer and domestic violence. To date, the “breast cancer crusade,” as it
was named, has received more attention and funds than the domestic violence project. As
of 2008, the Avon Foundation, through its breast cancer and domestic violence programs,
had raised and awarded over $660 million worldwide for “access to care and ﬁnding a
cure” for breast cancer and “awareness and support programs” for domestic violence
(Avon 2008; Avon 2005). The Avon Breast Cancer Crusade, founded in 1992 in the US
and the UK, has raised and awarded over $585 million in over 50 countries for breast
cancer research and access to care “with a focus on the medically underserved” (Avon
2008,2)

The Foundation is currently headed by Chairperson Robert Corti and Honorary
Chairperson and celebrity spokesperson, Reese Witherspoon (Avon 2008, 3). Robert
Corti oversees a ten-person board in charge of directing the Avon Foundation, both its
breast cancer and domestic violence initiatives (Table 4.4). As shown in Table 4.4, the
board members all have business backgrounds, many with a history in marketing and
global strategy and overseas development. Most board members have worked for the
Avon Company for many years and have moved up through a variety of positions within
the company. In contrast to SGKC’s board of directors, none of the Avon Foundation’s

board members have had breast cancer.

105

 

Table 4.4. Avon Foundation’s Board of Directors (2009)

 

 

 

 

 

 

 

 

 

Name/Position Occupational History (Position/Sector)

Robert Corti/Chairman Activision Blizzard (DirectorNideo Games); Avon Products
Inc.(Executive Vice President and CF O/Beauty); Bacardi Limited (Board
of Directors/Alcohol); ING Direct (Board of Directors/Insurance)

Brian ConnollyN ice Avon Products Inc. (Global Sales Strategy/Beauty)

President

Nancy Glaser/V ice Avon Products Inc. (Global Communications; Global Advertising and

President Public Relations/Beauty); Carl Byoir & Associates (Member of Executive
Committee/International Public Relations); American Museum of Natural
History (Public Relations/Arts); Metropolitan Hospital Center
(Communications/Medical)

Carol Kurzig/V ice Avon Products Inc. (Former Executive Director/Beauty)

President

Pauline Brown/V ice Avon Products Inc. (Global Business Development/Beauty); Estée Lauder

President (Corporate Strategy and New Business Development/Beauty); Bain &
Company (Global Business Consultant/Consulting); Smith McCabe
Ltd.(Director of European Business Development)

Andrea SIaterN ice Avon Products Inc. (Overseas Development; Marketing/Beauty)

President

 

 

Source: Avon Foundation Overview (2009); BusinessWeek (2009); WomensBiz (2005)

The Avon Breast Cancer Crusade also has a nine-member Scientiﬁc Advisory Board,
which consists of two breast cancer survivors with non-proﬁt experience and ﬁve
professionals representing prominent universities, medical centers, the National Institute
of Environmental Health Studies, and an international medical consulting ﬁrm (Table

4.5) (Avon 2008, 3).

106

Table 4.5. Avon Foundation’s Breast Cancer Crusade Scientiﬁc Advisory Board (2009)

 

 

 

 

 

 

 

 

 

 

 

 

Name Position Afﬁliation
Renee Bemett Survivor Advocate; Lay Department of Defense
Reviewer for Department of Breast Cancer Research
Defense Breast Cancer Research Program
Program
Matthew Ellis, MB, Ph.D., FRCP Associate Professor Washington University
School of Medicine
Julius Few, MD. Clinical Associate University of Chicago
Carrie Hunter, MD, Ph.D. President and CEO Oncology Consulting
lntemational
Elizabeth Morris, MD. Associate Radiologist and Breast MRI Memorial
Director Sloan-Kettering Cancer
Center
Christine Norton Survivor Advocate; Co- Minnesota Breast Cancer
Foundation of MBCC Coalition (MBCC)
Kenneth Olden, Ph.D., Sc.D., Director, Emeritus National Institute of
L.H.D. Environmental Health
Sciences
Amelie Ramirez, Dr.P.H., M.P.H. Director Institute for Health
Promotion Research,
University of Texas Health
Science Center at San
Antonio
Marc Hurlbert, Ph.D. Executive Secretary Scientiﬁc Advisory Board

 

 

 

Source: Avon Foundation Impact Report: 2007-2008
http://www.avoncompany.com/women/avonfoundation/impactreport.pdf

Avon has become the second largest non-governmental funder of breast cancer
research and care programs, following Susan G. Komen’s $750 million investment from
1985-2005, and leading the Breast Cancer Research Foundation, founded by Evelyn
Lauder, and Revlon, which have invested $117 million and $60 million, respectively,
since 1992 (King 2006, xxiv). Numerous Avon Crusade programs raise funds and
awareness for the breast cancer cause, such as the US Avon Walk for Breast Cancer
series, the global Walk Around the World for Breast Cancer and the sale of Breast Cancer
Crusade pink ribbon products worldwide. The funds raised are allocated by the
foundation to leading cancer centers as well as community-based non-proﬁt health

programs in ﬁve areas: “awareness and education; screening and diagnosis; access to

107

treatment; support services; and scientiﬁc research, all with a focus on the medically
underserved” (Avon 2008, 5).

Like SGKC, the Avon Foundation has gained recognition as a large non-
governmental funder of breast cancer research and education. Because of its
organizational and ﬁnancial success, leaders of the Foundation state that their
organization is uniquely able to create “a powerful international network of research,
medical, social service, and community-based organizations focused on defeating breast
cancer” (my emphasis, Avon, 2008, 9), which would serve the interest of Avon Company
by expanding their image as the “Company for Women” in countries where they already

sell their beauty products.

REASONS FOR GLOBAL EXPANSION
According to King (2006, 81), “having successfully captured US public interest in

breast cancer, nonproﬁt organizations, pharmaceutical companies, and other corporations
have recently begun to pursue breast cancer-related activities overseas.” The global
expansion of SGKC and the Avon Foundation supports King’s claim. SGKC is touted by
its leaders as the organization that launched, and continues to lead, the “global breast
cancer movement.” SGKC advocates support this statement based on the fact that their
organization is the largest non-governmental funder of breast cancer research. Similarly,
the Avon Company, via its Foundation, describes itself as the “leading corporate
supporter in the battle against breast cancer,” stating that Avon “runs the most extensive
‘global’ breast cancer program, with more than ﬁfty countries participating in its
endeavors in 2004” (King 2006, 82). Therefore, while SGKC raises more money for

breast cancer research than any other breast cancer organization, Avon Foundation’s

108

Breast Cancer Crusade has a presence in more countries than any other breast cancer
organization. Both SGKC and the Avon Foundation pride themselves in being pioneers in
breast cancer advocacy: SGKC by developing an extensive ﬁrndraising program via
cause-related marketing and the Avon Foundation by being the ﬁrst company to “start
with the movement of awareness and doing something to increase the awareness of breast
cancer and raising money for a cause” (Gabriella Lopez, Personal Interview, Caguas,

Puerto Rico, September 14, 2007).19

Susan G. Komen for the Cure
Although the organization’s leadership refers to SGKC as a “grassroots breast cancer

movement,” as I demonstrated, the organization is actually an elite advocacy organization
utilizing corporate strategies for organizational expansion (i.e., afﬁliate expansion
modeling Chili’s expansion) and fundraising (i.e., marketing breast cancer-related
products). Just as corporations respond to a successful brand or product by seeking and
expanding to new markets in a process of continual grth (King 2006; Peterson 2008),
SGKC is globally expanding because of its success in capturing the US breast cancer
advocacy market.

Similar to how business owners reinvent their companies to reinvigorate their
brand and differentiate it from other similar brands, Susan Braun, the President and CEO
of SGKC during the organization’s 25th anniversary, oversaw the rebranding of SGKC. In
celebration of the 25th anniversary of the organization, the Board of Directors rebranded

the organization, changing its name from The Susan G. Komen Foundation to Susan G.

 

'9 Pseudonyms are used for all interviewees.

109

Komen for the Cure and introducing a new logo, distinct from other pink ribbons, which
had become ubiquitous in the US over the past 25 years (Figure 4.4).

Figure 4.4. New SGKC Name and Logo

 

O
susan G.

Komen
FORTHE cure

Source: Susan G. Komen for the Cure, www.komen.org

 

 

 

In discussing the brand name change, the Chair of Atlanta’s SGKC afﬁliate
stated,
As the only organization ﬁghting to cure breast cancer at every stage, the vision
of Susan G. Komen for the Cure is to save lives by empowering people, ensuring
quality care for all and energizing science to ﬁnd the cures. The new brand
encompasses the vision with a unique logo — a “moving ribbon ” symbolizing the
energy and forward momentum in the race to ﬁnd a cure (my emphasis, SGKC
2007)
Differentiating themselves from other breast cancer advocacy organizations by stating
that they are ﬁghting to cure breast cancer “at every stage” and stating that the new
“unique” logo represents “energy and forward momentum,” SGKC leaders demonstrate
their desire to reinvigorate their brand and distinguish SGKC from similar organizations
in moving forward. SGKC leaders do not present the organization as working with all of
the related breast cancer advocacy organizations in a joint effort to eradicate the disease.

Rather, the rebranding effort sets them apart in terms of their mission, presenting SGKC

as the superior breast cancer advocacy organization.

110

Global expansion provided an avenue for SGKC to differentiate itself from
similar advocacy organizations as well as reinvigorate the organization by doing
something new, allowing SGKC to redeﬁne itself as the “leader of the global breast
cancer movement.” Through this global expansion, SGKC leaders were able to redeﬁne
their organization to US audiences, emphasizing the global reach of the organization,
while expanding their brand of breast cancer advocacy to new audiences in other
countries. In Puerto Rico, one of the locations where SGKC expanded via the
establishment of an international afﬁliate, a few small grassroots breast cancer support
and advocacy organizations already existed, but SGKC did not partner with them upon
the organization’s development on the island, maintaining a separate identity.20

Through its global expansion, the recognition of the SGKC brand remained
important to organizational leadership. As Carmen Arollo, a Komen Puerto Rico
organizer stated,

Breast cancer is known for the pink ribbon, so they [SGKC] have a different one,

now we have this new one, the running one. So it’s like, that ’s our branding.

That’s what we want to do, like everybody who sees that recognizes Susan G.

Komen. They recognize us as the trusted brand of breast cancer advocacy, but the

pink ribbon is just for breast cancer in general (my emphasis, Personal Interview,

San Juan, Puerto Rico, September 12, 2007).

As this statement exempliﬁes, SGKC is expanding globally as a unique brand of breast
cancer advocacy. SGKC advocates seek to set the organization apart from other advocacy
organizations by establishing it as “the trusted brand of breast cancer advocacy,” just as

companies compete with regard to their products. Moreover, according to Sara Friedman,

who heads SGKC’s international program initiatives, SGKC is very selective about

 

2° The trajectory of SGKC’s global expansion, including the organization’s international locations and
forms of global expansion will be discussed in detail in the next section.

111

which organizations it trains in its model of advocacy through the Course for the Cure, a
program designed to train international advocates. As she stated,
Because we have to be very, you know, very selective in determining who we
would want to partner with because as a nonproﬁt, the only thing that we really
have is our brand That is what we have to protect more than anything else, so
that is something that is always, you know, quite important to us (Telephone
Interview, November 16, 2008).
As this statement demonstrates, while SGKC expanded to differentiate itself from other
breast cancer advocacy organizations, reinvigorate its brand image, and expand its mode
of advocacy to new locations, the organizational leadership acted selectively to maintain
the integrity of the brand. This may explain why the organization has not aggressively
expanded internationally, but instead has acted on opportunities to expand in partnership
with the US government, the Fred Hutchinson Cancer Research Center and in partnership
with trusted medical professionals, discussed in detail in Chapter 6. As shown in Table
4.6, SGKC expanded via international afﬁliates from 2000 to 2003. In 2006, the
organization began collaborating with the US government to create breast cancer
advocacy initiatives, ﬁrst in the Middle East, then in Central and South America and

ﬁnally in other countries based on its collaboration with the Fred Hutchinson Cancer

Research Center.

112

Table 4.6. SGKC’s International Expansion Trajectory

International Afﬁliate
Locations
(established 2000-2003)
German}

Italy
Puerto Rico

 

 

 

 

 

 

US-Middle East Partnership
for Breast Cancer
Awareness and Research
Locations (established 2006-
2007)

Jordan
Saudi Arabia
United Arab Emirates

 

 

 

 

 

Partnership for Breast
Cancer Awareness and
Research in the Americas
Locations
(established in 2003
Brazil
Costa Rica
Mexico
Panama

 

 

 

 

 

 

Global Initiative for Breast
Cancer Awareness
Locations
(established 2007-2009)
Ghana
India"

Romania
Ukraine
Source: Telephone Interview with Sara Friedman, SGKC Advocate with lntemational Programs, October

29, 2008
'The initiative in India has not begun yet, but is scheduled to start in 2009 or 2010.

 

 

 

 

 

 

 

In sum, after 25 years of working in the US, where messages of breast cancer
awareness are now ubiquitous, leaders of SGKC rebranded the organization to
reinvigorate the organization and differentiate themselves from other breast cancer
advocacy organizations. Priding themselves on being at the forefront of breast cancer

advocacy and having exhausted expansion efforts within the US, leaders of SGKC began

113

of advocacy, rather than aggressively expanding to many countries, SGKC strategically

partnered with trusted individuals in their expansion efforts (see Chapter 6).

Avon Foundation
In her analysis of breast cancer philanthropy, King (2006, 84) argues that global

corporate philanthropy and community relations programs “are often cursory efforts that
are more effective in building a coherent and readily identiﬁable ‘global’ brand image
than they are in tackling the speciﬁc issues they purport to address.” Elaborating, King
(2006, 84) argues,

In other words, as corporations seek to produce and sell goods in an ever-

expanding number of locations, philanthropy and community relations are

increasingly deployed not merely to further some social good, but as techniques
for market penetration and retention, both in the domestic market and abroad.
The Avon Foundation, as discussed by King (2006) as well, has been deployed globally
by the Avon Company in order to expand Avon’s brand recognition and to promote brand
loyalty by demonstrating Avon’s commitment to women.

The Avon Company prides itself in being “The Company for Women” and, more
recently, “the girl-powered beauty brand” (Avon 2008). According to the Company’s
most recent Impact Report (Avon 2008), “Avon, whose name appears on more beauty
products than any other brand in the world, has an unmatched commitment to breast
cancer charities,” donating proceeds from pink ribbon products for research, education,
and treatment for breast cancer sufferers. While Avon is the largest distributor of beauty
products globally, the Company’s success varies geographically. In particular sales in the
US have slowed over the past ten years, likely because the door-to-door sale of beauty

products, pioneered by the Avon Company to help women make their own money at a

time when many women did not have careers, is no longer appealing to women who

114

time when many women did not have careers, is no longer appealing to women who
pursue careers or other types of part-time work. At the same time that Avon sales have
slowed in the US, according to King (2006, 86),
[p]roﬁts garnered elsewhere have continued to grow steadily and commentators
point to Avon’s success in the Latin American and Asian markets, in particular, as
the reason for their survival. Avon obtains two-thirds of its revenues from
overseas transactions, and markets in Asia, Eastern Europe, and Latin America
commonly post double-digit increases in sales and proﬁts.
As this statement suggests, to survive as a company, Avon has shifted its focus away
from the declining US market and toward the thriving markets in Latin American,
Eastern European, and Asian countries and potentially emerging markets elsewhere (see
Table 4.7). By expanding the Foundation along with the Company, Avon increases
exposure to their brand while demonstrating Avon’s commitment to women through their

breast cancer advocacy projects in order to give the company an edge in these markets.

Table 4.7. Avon Foundation’s International Expansion Locations*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Year Location
Established
1992 United Kingdom, Agentina
1993 Canada, Mexico, Puerto Rico
1994 Malaysia, Philippines, Spain, Venezuela
1995 Brazil, Indonesia, Turkey
1996 Australia, New Zealand
1997 Chile, Italy
1998 Hungary, Ireland, Poland, Slovakia, Thailand
1999 Ecuador, Portugal, Taiwan
2001 Bulgaria, Guatemala, Ukraine, South Africa
2002 China, El Salvador, Japan, Lithuania
2003 Czech Republic, Germany, Honduras, Slovenia
2005 Bolivia, Dominican Republic", Estonia, France,
Greece, India", Latvia", Peru“, Romania",
Russia"
2006 Oman
2007 Bosnia, Colombia, Finland, United Arab Emirates,
Macedonia, Serbia"
2008 Kazakhstan"

 

 

 

 

Source: King (2006), Table 1; Avon Foundation Walk Around the World for Breast Cancer countries,
http://walk.avonfoundation.org/site/PageServer?pagename=WorldWalk_Main.

'1 am not sure how the Avon Foundation decided on the order in which to expand the Foundation, except
that it seems to be correlated with how established the Company was in each country. For example, the

115

In Puerto Rico, for example, the expansion of the Avon Foundation and the Avon
Breast Cancer Crusade events are directly related to the reputation of the Avon Company.
As Gabriella Lopez, the Avon representative in charge of the Breast Cancer Crusade in
Puerto Rico, stated
Each year the Avon Company does a tracking study in all the categories {e.g.,
fragrances, cosmetics] and they also include the breast cancer campaign. Phone
calls are made here in Puerto Rico and they are made in different countries. This
[the chart she was showing me] is for Puerto Rico only. They have a sample of
people they call and they ask these questions and they came out with the results
and I was very impressed that the increase of our efforts in raising awareness
about Avon and breast cancer. In 2003 it stayed ﬂat, 2005 raised to 49%, 2006 to
68%, and they compared to other companies and Avon’s was the most recognized
breast cancer company campaign. They asked “do you know what efforts Avon is
making?” They ask if you have seen Avon’s campaign. Then the people answer
yes or no, so that’s the percents. We are very proud of this (Personal Interview,
Caguas, Puerto Rico, September 14, 2007).
As the results of Avon’s survey in Puerto Rico demonstrate, Avon Foundation’s Breast
Cancer Crusade events raise awareness, not only about breast cancer, but about the Avon
Company. By expanding their message of breast cancer awareness, the Avon Foundation
promotes the Avon Company as the brand that cares about women, reinforcing the
company’s tagline. Currently in Puerto Rico, an increasing number of corporations are
using cause-related marketing to demonstrate the company’s commitment to breast
cancer. According to Gabriella Lopez, as of September 2007, Pﬁzer, Johnson & Johnson,
Proctor & Gamble, Elizabeth Arden, Estée Lauder, and Avon all engaged in some type of
sponsorship of breast cancer events or cause-related marketing campaign to demonstrate

their commitment to the breast cancer cause and promote their company as “woman-

ﬁiendly.” In fact, according to Gabriella,

116

We are not competing with the other companies because it’s the same message of

awareness that we are going to deliver and we want the message to be expressed.

So we are very proud that each year many more companies are doing something

for breast cancer. So it’s not a competition. We ﬁnd that its great if in each year

we have more and more companies doing something for breast cancer (Personal

Interview, Caguas, Puerto Rico, September 14, 2007).

Despite this statement, the Avon Company conducts this survey each year to determine
Avon’s brand recognition via its foundation’s breast cancer advocacy projects in
comparison to other companies’ brand recognition. The survey in Puerto Rico, for
example, included questions about all of the companies engaging in some type of breast
cancer project on the island. The Avon survey, therefore, did not assess an overall
increase in breast cancer awareness in Puerto Rico, but awareness about the Avon brand
through its foundation in comparison to other companies.

In sum, with slowing sales in the US, the Avon Company refocused its attention
on lucrative international markets and potential emerging markets. By extending Avon
Foundation’s breast cancer advocacy projects to international locations where Avon
already operated, the Company solidiﬁed its reputation as the “Company for Women.”

This reputation is increasingly difﬁcult to maintain with the proliferation of breast cancer

cause-related marketing projects in the US, and in other countries as well.

CONCLUSION

Given SGKC’s and the Avon Foundation’s elite and corporate origins it could be argued
that they should not be discussed as social movement or advocacy organizations at all.
King’s (2006) research focused on the Avon Foundation, referring to it as “corporate
philanthropy.” Despite Avon Company’s control over Avon Foundation’s expansion, the
foundation promotes a speciﬁc type of advocacy (e.g., biomedical, cause-related

marketing projects), which, along with SGKC, it has successfully promoted in the US and

117

is now expanding to over 50 countries. Similarly, even though SGKC has elite origins
and access to prominent medical, governmental and corporate partners in addition to
conducting its affairs utilizing a corporate model of continual growth and marketing
concepts for fundraising strategies, it is important that we not ignore this organization as
a type of social movement organization because it is promoting a particular brand of
advocacy that has caught on in the US and is now being introduced in a number of
countries.

Despite the elite and corporate nature of these organizations, SGKC and Avon
Foundation are presented by their members as “grassroots movements” consisting of
“activists” and “advocates,” thereby masking their organizational clout. This is
signiﬁcant because given their organizational and ﬁnancial resources, these organizations
have the potential to be much more successful/inﬂuential in promoting their advocacy
agendas than actual grassroots movements, which typically lack anything resembling the

resources of these organizations.

118

CHAPTER 5
THE SOCIAL CONSTRUCTION OF A GLOBAL BREAST CANCER CRISIS

According to Brown (1995), in exploring how illnesses are socially constructed we are
actually investigating how social forces shape our understanding of and actions toward
health, illness, and healing. Social constructions of diseases are signiﬁcant in that they are
“powerful channels for the expression, legitimization, and expansion of certain groups’
social power” (Lantz 1998, 909). Speciﬁcally, Foucault (1973) argued that the social
construction of diseases serves to establish and solidify the authority of professionals,
particularly medical professionals, over the individual. The social construction of a
disease as an epidemic, therefore, is a powerful means of deﬁning a social problem,
demanding resources for its alleviation, and reifying the authority of “experts,” both
experienced advocates and medical professionals, as those with the ability to rectify the
problem.

As discussed in Chapter 2, health social movements have participated in processes
of socially constructing various diseases. The process of meaning-making in which
advocates engage, referred to in the social movement literature as framing, involves the
creation of a shared understanding of an issue, that requires action on the part of the
advocates and legitimizes the existence of their organization(s) (Benford 2000). Based on
her research on biomedical breast cancer advocacy in the US in the 19905, Kolker (2005,
825) argues that breast cancer advocates created a sense of urgency around breast cancer
by socially constructing it as “an epidemic.” By doing so, breast cancer advocates
legitimized the need for their organizations to attain ﬁnancial resources, public support,

governmental attention, and medical researchers’ attention. Additionally, advocates

119

framed breast cancer as a problem of gender equity, arguing that because it is a disease
that almost exclusively affects women, it had been under-funded by the government and
overlooked by medical researchers. Finally, advocates framed breast cancer as a threat to
families, in that, by affecting women during their thirties, forties and ﬁfties, husbands
often lost their wives and children their mothers, thereby creating social disorder (Kolker
2005).

My ﬁndings demonstrate that SGKC and the Avon Foundation, in the promotion
of their brand of biomedical breast cancer advocacy, continue to socially construct the
problem of breast cancer, now on a global scale. According to Benford and Snow (2000,
624), social movement organizations engage in frame alignment processes, which are
deliberative, strategic, and goal-oriented. Globally expanding biomedical breast cancer
advocacy organizations are engaging in processes of “frame diffusion” by actively
transmitting their framing of breast cancer to other political and cultural contexts
(Benford and Snow 2000, 627). By engaging in processes of “strategic ﬁtting,” these
organizations are tailoring their frames, not to ﬁt a speciﬁc host culture, as Benford and
Snow (2000, 627) discuss, but rather to apply more generally across cultures, as a global
issue, requiring a global movement and a global solution.

To strategically ﬁt their frames to a global community, SGKC and the Avon
Foundation have extended their framing of breast cancer as a US epidemic to framing the
disease as a global epidemic, with the potential to affect women everywhere. No longer
framed as an issue of gender equity, biomedical breast cancer advocates are constructing
the disease as an issue of global health inequality. Biomedical breast cancer advocates

argue that women in the US have attained a high level of breast cancer awareness,

120

leading to early detection, and thereby lowering the US breast cancer mortality rate. At
the same time other countries, particularly developing countries, are still struggling with
issues of social stigma, myths, and misinformation about breast cancer. Thus, these
organizations argue that women in other countries do not have an equal opportunity to
survive breast cancer and by expanding their organizations to these locations, they are
increasing global health equality. Finally, breast cancer is still framed by biomedical
breast cancer advocates as a threat to families. US biomedical breast cancer advocates
often draw on their experience as mothers, sisters, wives and daughters to connect US
women’s experiences with breast cancer with women’s experiences with the disease
globally. These organizations, therefore, explain their global expansion as an effort to
combat the global epidemic of breast cancer, global health inequality and the threat posed
by breast cancer to families by spreading their advocacy model, emphasizing awareness
and early detection, a campaign that has proven successful in the US.

SGKC and the Avon Foundation began to refrarne their efforts in confronting
breast cancer by shifting from a national to an international scale in the mid to late 19903
after SGKC had expanded throughout all of the US and the Avon Company was
experiencing stagnation in the US market, while observing increasing success in
international markets. To justify their global expansion, leaders from both organizations
constructed breast cancer as a pressing global health crisis in need of a global biomedical
breast cancer movement, which SGKC and Avon Foundation leaders claimed to be
equipped to lead based on their success in the US. In this chapter, I demonstrate SGKC
and Avon Foundation leaders’ framing of a global breast cancer crisis while

simultaneously challenging the claim that breast cancer is a global health crisis in need of

121

a global biomedical breast cancer movement. I do this by examining how biomedical
breast cancer advocates have actively constructed breast cancer as a global epidemic and
crisis in light of actual global breast cancer incidence and mortality rates. Additionally, I
argue that advocates from both organizations frame the causes of the global breast cancer
problem as a lack of awareness of and education about breast cancer leading to low levels
of early detection, thereby positioning their biomedical advocacy model as the
appropriate solution to the problem.

BREAST CANCER AS A GLOBAL EPIDEMIC

Beginning in the 19905 and increasing in the 20005, SGKC and the Avon Foundation
abandoned their exclusive focus on breast cancer in the US, and shifted their attention to
the global burden of breast cancer. As discussed in Chapter 1 and depicted in Figure 5.1,
the global burden of breast cancer is quite uneven, with the majority of cases still
appearing in the US, Canada, Western European countries, Australia, New Zealand, and
Argentina. Incidence rates remain relatively low in Central America, Eastern Europe,
Asia, Africa, and parts of South America (see Figure 5.1).

While global breast cancer incidence rates vary widely by geographic region,
representatives of SGKC and the Avon Foundation often emphasize the general trend of
increasing incidence rates, providing a justiﬁcation for the need for their organizations to
expand globally as well as motivational framing to recruit new allies and participants
based on the severity of the problem. In explaining the need for their Walk Around the
World for Breast Cancer events, Avon representatives often repeat the following
statement, “Breast cancer remains the most commonly diagnosed cancer among women

worldwide. According to the World Health Organization, breast cancer is responsible for

122

502,000 deaths per year worldwide” (Avon Foundation 2007). Similarly, SGKC leaders
argue that “with more than one million women worldwide receiving a breast cancer
diagnosis each year, the organization believes it is critical to increase advocacy for and
education about this life-threatening disease” (SGKC 2008).

Figure 5.1. Age-Standardized Incidence Rates of Breast Cancer, 2002*

 

   

I < 19.5 F“ < 25.8 < 34.3 I < 54.4 . (101.1

 

 

 

Source: IARC, Globocan 2002
*Age-standardized rates (ASR world standard) per 100,000 of the population

Sometimes, rather than emphasizing the global incidence rates, which remain
lower in many countries than in the US, SGKC and the Avon Foundation instead
emphasize mortality rates from breast cancer in conjunction with incidence rates or by
themselves. Similar to breast cancer incidence rates, mortality rates also vary
signiﬁcantly worldwide (see Figure 5.2). In explaining the need for breast cancer
advocacy on a global scale, an Avon Foundation representative stated that “although
progress has been made, breast cancer continues to be a leading cause of death for

women, accounting for 1.6 percent of all female deaths worldwide” (Avon Foundation

123

2005). The chairman and director of the Breast Health Global Initiative, founded by
SGKC and the Fred Hutchinson Cancer Research Center, stated
Breast cancer is a problem of global proportion and the magnitude of this problem
cannot be overestimated. In the United States, one in ﬁve women diagnosed with

breast cancer will die from the disease and the mortality rate is more dire in
developing countries (SGKC 2007).

Figure 5.2. Age-Standardized Mortality Rates of Breast Cancer, 2002*

 

 

I (10.5 < 14.0 < 17.0 I (19.9 I < 29.5

 

 

 

Source: IARC Globocan 2002
‘Age-standardized rates (ASR world standard) per 100,000 of the population

While the breast cancer mortality rates in developing countries are high relative to their
lower incidence rates, the mortality rate due to breast cancer, when compared to other
diseases affecting women in many developing countries, is not particularly high. In her
argument about why the global expansion of SGKC is crucial, Nancy Brinker stated that
“an estimated 25 million women will be diagnosed with breast cancer and 10 million

could die in the next 25 years without the cure” (SGKC 2007). All of these arguments

124

made by biomedical breast cancer advocates emphasize the severity of the global burden
of breast cancer in order to justify their expansion and motivate potential participants and
allies to collaborate in their efforts.

In addition to framing the global burden of breast cancer in terms of its severity,
biomedical breast cancer organizations also emphasize the urgency of the issue in order
to explain their expansion and motivate potential participants and allies. Whether
addressing breast cancer incidence rates, mortality rates, or both, SGKC and the Avon
Foundation consistently frame breast cancer as a global crisis in need of immediate
attention. This is a common form of rhetoric used with cancer in general, as argued by
Sontag (1989). Such dreaded diseases, require a “ﬁght,” “crusade” or “war” (Sontag
1989, 57). For example, Nancy Brinker, in promoting the Ignite the Promise Global
Advocate Summit, stated “alarming global cancer statistics underscore the urgency of
Komen’s mission to end breast cancer forever, and to attack breast cancer on domestic as
well as international fronts” (my emphasis, SGKC 2007). In the same speech, she later
insisted that “while we have made many strides, the breast cancer crisis facing our world
is enormous” (my emphasis, SGKC 2007). When referring to global breast cancer rates,
instead of actually stating the statistics, in some cases SGKC and Avon Foundation
representatives will make a blanket statement about the global burden of breast cancer,
such as “staggering incidence and mortality rates throughout the world” (my emphasis,
SGKC 2008). Biomedical breast cancer advocates’ consistent use of crisis rhetoric frames
breast cancer as a pressing global health issue in need of immediate attention.

To emphasize the severity and urgency of global breast cancer rates, biomedical

breast cancer advocates often refrain from discussing breast cancer in the context of other

125

diseases affecting women globally, the reality of which might undermine their arguments
regarding the severity and urgency of breast cancer internationally. In cases where they
want to contextualize breast cancer among the global burdens of other diseases, they
often draw on general cancer statistics, rather than solely breast cancer statistics to
emphasize the dire need for global breast cancer advocacy. As Nancy Brinker stated in
her announcement of the Global Advocate Summit in Budapest, “cancer already claims
twice as many lives as AIDS worldwide. At least seven million people die of cancer each
year and close to 11 million new cases are diagnosed. That’s more than AIDS,
tuberculosis, and malaria put together” (SGKC 2007). Given that she is announcing a
summit addressing only breast cancer, it is likely that unless listening closely, audiences
may assume that these statistics refer only to breast cancer. Relying on general cancer
statistics in contexts where audiences are expecting to hear about breast cancer makes the
statistics sound even more alarming than simply relying on global breast cancer statistics
alone.

By framing breast cancer as a severe and urgent global women’s health issue,
biomedical breast cancer organizations are socially constructing the disease as a global
epidemic in need of immediate attention. Given that the majority of breast cancer cases
still exist in the US, Canada, Western European countries, Australia, New Zealand and
Argentina, a single global approach to breast cancer may not be needed. Furthermore,
constructing breast cancer as a global epidemic or crisis is misleading, given the uneven
distribution of breast cancer globally. Rather, strategic efforts in particular countries may
be needed where breast cancer incidence rates are in fact quite high. As discussed in

Chapter 4, SGKC expanded to countries based on partnerships with the US government,

126

medical professionals, and medical centers, rather than based on the need for breast
cancer advocacy in certain countries whereas the Avon Company directed the expansion
of the Avon Foundation based on the desire to solidify their international markets. Both
organizations expanded to countries where the incidence rates of breast cancer are not
high. Instead of always emphasizing the global incidence of breast cancer, both
organizations also stressed the global mortality rate from breast cancer. While it is true
that some countries have incidence rates lower than the US, but higher mortality rates, it
is a leap to assume that this is due primarily to the lack of awareness, which is the
solution that both organizations advocate. As argued in the World Health Organization’s
most recent report on the world’s health, the main factor negatively inﬂuencing health
globally is the lack of primary healthcare (WHO 2008). Finally, to argue that breast
cancer is a greater global health problem than AIDS, tuberculosis or any other disease,
these organizations rely on general cancer statistics. In reality, while cancer is becoming
increasingly prevalent in many countries this can at least partially be attributed to
increased life expectancy, as cancer still is largely a disease of advanced age. It is also
arguably linked to processes of industrialization. Industrialized countries, like the US,
have the highest rates of cancer, including breast cancer, and as countries industrialize
and populations are exposed to an increasing number of chemicals, the cancer rate may
increase as well. While there is an increase in cancer globally, this does not diminish the
fact that for many countries cancer is not the predominant health priority.

BREAST CANCER AND GLOBAL HEALTH INEQUALITY

In addition to framing their global efforts in terms of the severity and urgency of the

global burden of breast cancer, biomedical breast cancer advocacy organizations also

127

present their expansion as a necessary means of addressing global health inequality,
speciﬁcally with regard to breast cancer. In the US, breast cancer advocates often
emphasized the issue of gender equity, arguing that because it is a disease predominantly
affecting women, breast cancer is under-funded and researched (Kolker 2005). On a
global scale, rather than framing the issue in terms of gender equity, biomedical breast
cancer advocates frame the disease as an issue of global inequality in which the US has
been able to reduce its breast cancer mortality rate, largely due to the work of biomedical
breast cancer organizations in promoting awareness, education, and early detection.
Biomedical breast cancer advocates argue that developing countries deserve their
attention as well as the attention of their respective governments, medical professionals
and other organizations committed to helping women. Nancy Brinker demonstrates this
sentiment by stating,
For nearly 25 years, the Komen Foundation has mastered scientiﬁc and
community research funding, putting dollars into ideas that no one else has
funded, yielding discoveries that have signiﬁcantly changed how we detect,
diagnose, treat and manage this disease. And, while we have made great progress,
a desperate situation continues to exist in our world and millions of people have
no access to those discoveries. So, we are challenging ourselves and others to put
the full weight of our resources behind efforts to attack the disparities problem in
new ways (SGKC 2006).
In her statement, Nancy Brinker emphasizes that SGKC has been incredibly successful in
the US with regard to raising a signiﬁcant amount of money, which the organization then
funnels into breast cancer research. She argues that given the success of the organization
in the US, it is now up to US biomedical breast cancer advocates to challenge global
breast health disparities.

As stated at the conclusion of the previous section, the global burden of breast

cancer is very uneven, still predominantly affecting women in the most industrialized

128

countries. Therefore, to effectively address global health concerns, women’s health
priorities and country-speciﬁc disease statistics would need to be taken into account and,
in many cases, breast cancer may not be a health priority, nor a signiﬁcant health concern
in comparison to other diseases. Additionally, while the statement by Nancy Brinker
implies that the global expansion of the organization is targeted at increasing access to
medical advances, both SGKC and the Avon Foundation focus their international
advocacy efforts on raising awareness about breast cancer, as I discuss in the following

sections.

Social Stigma, Myths, and Misinformation in Developing Countries
Advocates from SGKC and the Avon Foundation credit biomedical “awareness”

advocacy with the lowering of breast cancer mortality in the US. They argue that in
countering myths and social stigma previously surrounding the disease, by raising
awareness about breast cancer and educating women about the importance of early
detection, biomedical breast cancer advocates reduced breast cancer mortality in the US
by increasing early detection.21 SGKC and the Avon Foundation often stress the social
stigma, myths, and misinformation still surrounding breast cancer in other countries,
particularly in developing countries, which they argue are preventing early detection of
breast cancer, leading to higher mortality rates from breast cancer in the 3rd world.
Biomedical breast cancer advocates argue that as in the US prior to biomedical

breast cancer advocacy, breast cancer is a fear-inducing and socially stigmatizing disease

 

2' Between 1975 and 1990, the breast cancer mortality rate for all races combined increased by 0.4 percent
annually in the US. Between 1990 and 2002, the rate decreased by 2.3 percent annually. The percentage of
decline was larger among women under 50. The mortality rate for white women decreased more than the
rate for women in other racial and ethnic groups. Medical experts attribute the decline in mortality rate to
both improvements in breast cancer treatment and early detection. Nevertheless, there is debate among
experts regarding the role of each in the decline in mortality rate (American Cancer Society 2006).

129

in developing countries, often leading to late-stage diagnosis and high mortality rates
from the disease. In 2005, when the Avon Foundation celebrated its 50th Anniversary
with events in nearly 40 countries, Avon Foundation President at the time, Kathleen
Walas, in discussing the need for global breast cancer advocacy, stated that “In many
nations breast cancer still carries a powerful stigma. Although progress has been made,
breast cancer continues to be a leading cause of death for women” (Avon Foundation
2005). Similarly, leaders of SGKC and the BHGI presented the Ignite the Promise Global
Advocate Summit in Budapest, Hungary in 2007 as an opportunity for international
delegates to share “strategies on how to increase awareness about breast cancer, early
detection and treatment options in their communities, with the goal of reducing stigma
surrounding this often taboo disease” (SGKC 2007). One of the SGKC international
delegates from India stated that “It is crucial to educate the community. We must bust
some of the myths about this disease—such as cancer is contagious or god is punishing
you—so that women can express themselves and their health needs” (SGKC 2007). The
Avon Foundation and SGKC argue that despite their current efforts, there is still much
work to be done in countering the powerful stigma surrounding breast cancer globally.

In addition to the challenge to early detection and treatment posed by the social
stigma surrounding breast cancer in developing countries, biomedical breast cancer
advocates also emphasize the myths, misinformation and lack of information about breast
cancer plaguing many developing countries. In a National Public Radio interview,
Gabrielle Union, a Celebrity Ambassador of Hope for SGKC, reported on her visit to
Ghana for SGKC (2008), stating that,

The biggest thing is just reaching out to survivors and dispelling myths, you
know, as much as I hate rumors and gossip in the United States, they don’t kill

130

me, but in Ghana you know where people think if you put change in your bra that
you can get breast cancer that way. There are so many different crazy myths about
how you can acquire the disease and treatments, that if you go to the hospital here
you’re going to die, they’re going to cut off your boobs and you’re going to die
anyway. So just getting the word out, showing people that there are survivors, this
doesn’t have to be a death sentence and pointing people in the direction of
treatment.

Biomedical breast cancer advocates argue that it is women not knowing about early
detection that leads to mortality from breast cancer in developing countries, rather than
lack of access to healthcare, lack of medical expertise in breast cancer, or lack of
adequate detection and treatment technologies. In collaboration with the Tanzania Breast
Cancer Foundation, SGKC held the ﬁrst Race for the Cure event in Tanzania in 2008. At
the event, SGKC and Tanzania Breast Cancer Foundation advocates recounted the story

of a Tanzanian woman named Zubeda who died of breast cancer, stating that,

Zubeda discovered a breast lump in 2003 and visited a traditional healer for help.
When that approach did not work, she reluctantly sought medical attention. By the
time she agreed to undergo a mastectomy in 2006, the cancer had spread. By the
last months of 2007, her arm was so swollen and painful she could not move it or
touch it. The only painkillers she had were weak and ineffective as the cancer
invaded her liver, lungs and bones. Before Zubeda died in March 2008, she
agreed to be photographed. The pictures show a woman who died - needlessly and
in great pain - because she did not have the right information at her fingertips. By
not knowing about early detection and the curability and survivability of breast
cancer in its earliest stages, Zubeda lost her life (my emphasis, SGKC 2008).

This story demonstrates biomedical breast cancer advocates’ view that it is the lack of
information about early detection that leads to needless death and suffering for women in
developing countries. In 2006, Avon China held the ﬁrst Avon Walk Around the World
for Breast Cancer event in a poor rural area in Southern China.

According to a joint survey conducted by Avon China and the Conghua Women’s

Association, prior to this event nearly 70 percent of women interviewed had no
knowledge about breast cancer prevention, and over 80 percent had never

131

received a breast examination nor had they ever performed a self-examination

(Avon Foundation 2007).

SGKC and the Avon Foundation stress the social stigma, myths, misinformation and lack
of information surrounding breast cancer in developing countries as the reason for the
need for their global expansion. SGKC and the Avon Foundation frame the global burden
of breast cancer as affecting women in all countries, often glossing over signiﬁcant
incidence and mortality rate differences. In contrast, with regard to countries’ abilities to
address breast cancer, these organizations emphasize global inequalities. For example,
Carol Kurzig, the Executive Director of the Avon Foundation, stated that “breast cancer
does not discriminate between nations or ethnicities, but both the understanding and
support of the issue of breast cancer varies greatly [from] country to country” (Avon
Foundation 2007).

Although SGKC and the Avon Foundation have expanded to both developed and
developing countries, as mentioned previously, they often emphasize their expansion in
developing countries. Hala Moddelmog, President of SGKC, stated “Susan G. Komen for
the Cure already has changed the way we talk about and treat breast cancer in the United
States, and we’re bringing what we’ve learned to developing countries in Asia, Aﬁica,
Latin America, the Middle East and Eastern Europe” (SGKC 2008). Susan G. Komen for
the Cure and the Breast Health Global Initiative, of which SGKC is a co-founder, often
stress that while breast cancer has been a health problem predominantly in developed
countries, that is currently changing and their organizations are one step ahead of the shift
by addressing breast cancer in developing countries. As Nancy Brinker put it,

More than 25 million cases of breast cancer are expected to be diagnosed over the
next 25 years, with more than 70 percent expected in developing countries, where

132

cultural and economic issues create barriers to care. To address these issues,
Komen for the Cure formally expanded its lntemational work by launching a
global breast cancer initiative in 2007. Earlier this year, Komen launched the
Global Promise Fund, with attention focused on partnerships in the Middle East,
Latin America, Eastern Europe and Aﬁica. By doing this, Komen for the Cure will
address breast cancer in developing countries before the crisis worsens (my
emphasis, SGKC 2008).

In this statement, Nancy Brinker makes a case for organizational expansion to developing
countries, despite the current lack of high breast cancer incidence rates. Other advocates
working with SGKC echoed this sentiment. As Francisco Bacci, a Komen Italia advocate
and Global Breast Advocacy Summit delegate, stated,
There is a lot of work to do in developing countries where cancer is still today not
a major priority. But it will, according to the epidemiological studies, in 20 years
become a major health problem also in these countries. And where the face of
breast cancer is completely different, meaning 70 percent of cases are locally
advanced, or metastatic, very difficult to treat, very expensive with very limited
resources available and no action going on, no interest about doing something by
anyone. Just Komen, Komen is alreaay starting to focus on this. Because Komen
is starting to focus on this, this is already by itselﬂ from my point of view, a very
important thing and something that should be strongly encouraged (my emphasis,
Personal Interview, October 16, 2007).
Biomedical breast cancer advocates, therefore, present themselves as ﬁlling a signiﬁcant
gap in global breast cancer advocacy, in pursuit of global health equality with regard to
increasing women’s awareness of and knowledge about breast cancer and the importance
of early detection. Reiterating this point, Mansoor Wan Abdullah, General Manager for
Avon Malaysia, Thailand, Vietnam and Indonesia stated in his opening speech at the
Avon Malaysia Walk Around the World for Breast Cancer event in 2007,
let us all work together for a better tomorrow today where women across the
globe are adequately equipped to face this pandemic, subsequently becoming

more self-sufﬁcient, independent and able to beneﬁt from medical research and
success (Avon Foundation 2007).

133

Both SGKC advocates and Avon Foundation representatives present the problem in
developing countries as women’s lack of awareness of and education about breast cancer,
thereby hindering early detection. By arguing that this is the problem, rather than lack of
adequate healthcare services and treatment or even questioning why breast cancer rates
are increasing in developing countries to begin with, they are able to present their
organizations, which focus on awareness, education, and early detection, as the solution.
BREAST CANCER AS A THREAT TO FAMILIES
Finally, in framing breast cancer as a global issue, biomedical breast cancer advocates
emphasize the nearly universal role of women as crucial family members, particularly as
mothers, but also as daughters, sisters, and wives. In framing breast cancer as a threat to
families on a global scale, biomedical breast cancer advocates are amplifying a frame that
proved culturally resonant in the US (Kolker 2005). Motherhood is often assumed to be
an experience that unites all women regardless of political, economic, cultural or
geographic differences. By presenting breast cancer as a threat not only to women, but
also to families, biomedical breast cancer advocates trust that this frame will resonate in
diverse cultural and political contexts. In her speech in the United Arab Emirates
announcing the US-Middle East Partnership for Breast Cancer Awareness and Research,
Nancy Brinker, emphasizing the universal experience of breast cancer, despite cultural
and political differences, argued that,
Breast cancer is not an American disease. It is not an Arab disease. It is a disease
that can strike any woman, any family. And when it does - as it did my sister, and
then me - we all have the same fears, feel the same pain, cry the same tears and
pray for the same thing - to survive - for ourselves and our families (SGKC 2007).

In these opening remarks, Nancy Brinker puts her personal experience with breast cancer

into a universal context, in which all women, despite any differences they may have,

134

experience breast cancer as a threat to their personal well-being as well as a threat to their
families.

At international events, SGKC and Avon Foundation representatives often discuss
women in terms of their familial roles. In addition to appealing to women, presenting
women in terms of their familial roles frames breast cancer as a broader threat, in that it is
not only an issue for the isolated women who have breast cancer or may be diagnosed
with breast cancer, but also for all the people in their families who rely on them. The US
Ambassador to the Bahamas, in discussing the Bahamas Breast Cancer Initiative, a
partnership between the US Embassy in the Bahamas, SGKC, and the Cancer Society of
the Bahamas, stated that,

Since launching the Bahamas Breast Cancer Initiative, we have seen an

overwhelming amount of support in our effort to improve the odds for so many

Bahamian women through early detection, proper education and excellent care.

The turnout for this morning’s walk makes me even more conﬁdent we will be

able to save the lives of so many young Bahamian mothers, sisters, wives and

daughters who are at risk for contracting breast cancer (my emphasis, SGKC

2008)

In addition to addressing women in terms of their familial roles, biomedical breast cancer
advocates also present breast cancer as a direct threat to families, as SGKC’s Vice
President of the lntemational Division, Annetta Hewko, demonstrates in this statement at
a ceremony announcing Panarna’s involvement in the Partnership for Breast Cancer
Awareness and Research of the Americas. “Breast cancer is a disease that knows no
boundaries-it can strike any woman, any family, anywhere” (SGKC 2008). When a

woman is diagnosed with breast cancer, in other words, she not only suffers, her family

suffers.

135

Breast cancer, therefore, becomes a broad global social issue, not relegated to
“women’s issues.” Kathleen Walas, past-President of the Avon Foundation, in discussing
the trajectory of the Avon Foundation at the celebration of the organization’s 50th
Anniversary, stated “We want to honor our ﬁrst 50 years of the Avon Foundation by
setting the stage for an even stronger next half century. This celebration is in honor of the
women, men and families who have battled breast cancer across the globe and a
commitment to eradicating this disease in the future” (Avon Foundation 2005). Breast
cancer, therefore, becomes a health issue that is fought, not only by women, but also by

men and families internationally.

CONCLUSION: BIOMEDICAL BREAST CANCER ADVOCACY AS THE
SOLUTION

As argued by Brown (1995), in exploring how illnesses are socially constructed we are
actually investigating how social forces shape our understanding of and actions toward
health, illness, and healing. In this case, elite and corporate advocacy organizations are
taking a leading role in deﬁning how breast cancer should be addressed globally. By
shaping the understanding of breast cancer as a pressing global health issue and deﬁning
the problem as one of lack of awareness of and education about breast cancer, biomedical
breast cancer advocacy organizations are promoting awareness-raising and education
campaigns as the necessary actions to reducing global breast cancer rates, to the
noteworthy exclusion of broader healthcare reform.

In their discussion of the social construction of diseases, Lantz and Booth (1998,
909) argued that social constructions of diseases are signiﬁcant in that they are means for
the “legitimization and expansion of certain groups’ social power.” Given the extensive

organizational and ﬁnancial resources of SGKC and the Avon Foundation discussed in

136

the previous chapter, they both had the ability to expand globally, however, by reframing
breast cancer as a global health crisis, problem of global health inequality, and threat to
families, the organizations legitimized their expansion. By continually expanding its
organization, SGKC has been able to attract an ever-increasing amount of money,
allowing the Board of Directors and the Scientiﬁc Advisory Council to allocate the funds
according to their biomedical breast cancer agenda. The Avon Company is able to
solidify its international markets by socially constructing breast cancer as a global issue,
which its Foundation is well-equipped to address through awareness and education.
Finally, as argued by Foucault (1973), the social construction of diseases serves to
establish and solidify the authority of professionals, particularly medical professionals,
over the individual. The social construction of a disease as an epidemic, therefore, is a
powerful means of deﬁning a social problem, demanding resources for its alleviation, and
reifying the authority of “experts,” both experienced advocates and medical
professionals, as those with the ability to rectify the problem. By constructing breast
cancer as a global health crisis, SGKC and the Avon Foundation have legitirnated their
global expansion and reiﬁed their authority as “experts” with regard to their history of

breast cancer advocacy in the US.

137

CHAPTER 6

THE CONSTRUCTION OF TRANSNATIONAL MIXED ACTOR COALITIONS

As discussed in Chapter 2, transnational social movement (TSM) scholars have identiﬁed
a variety of forms of transnational advocacy organizational structures, ranging ﬁ'om
loosely connected informational networks, strictly NGO- and social movement-based
coalitions, and mixed actor coalitions. Although NGOS and social movements are the
primary actors within transnational mixed actor coalitions (MACS), (parts of) states and
intergovernmental organizations, as well as other non-state actors such as research
institutions and corporations could also be included as their members (Khagram et a1.
2002, 9). According to Khagram and his colleagues (2002, 11), the non-governmental
sector, of which TSMs and NGOs are a signiﬁcant part, represent a third sector of society
“distinct from, but interacting with, government and business, in which the characteristic
form of relation is neither authority or hierarchy, nor the market, but rather the informal
and horizontal network.”

The ﬁndings that I present in this chapter indicate that biomedical breast cancer
advocacy organizations have formed MACS, in which they are the central organizations,
but government agencies, medical professionals, medical research centers, corporations,
and local NGOS are also included. While Khagram and his colleagues (2002, 11), like
many other social movement scholars, argue that the non-governmental sector, and
speciﬁcally, social movements, represent a distinct sector of society, I found that in their
effort to globally expand, biomedical breast cancer advocacy organizations are intricately

tied to governmental, medical, and corporate sectors in ways that blur the boundaries

138

between their identities. This is signiﬁcant because it suggests that the non-governmental
or social movement sector of society may need to be reassessed with regard to its
increasing overlap with other powerful sectors of society.

In this chapter, I discuss Susan G. Komen for the Cure’s and the Avon
Foundation’s construction of transnational mixed actor coalitions separately, as they
developed independently of each other. In each section, I highlight the collaboration
between these biomedical breast cancer advocacy organizations and relevant
governmental, corporate, and/or medical sectors as well as other NGOs, demonstrating
the ways in which these alliances have blurred the boundaries between the various social
sectors.

SUSAN G. KOMEN FOR THE CURE: DEVELOPING A
TRANSNATIONAL MAC

Based on my research, I constructed Figure 6.1 as a visual representation of the SGKC
transnational mixed actor coalition. To expand globally, SGKC collaborated with medical
professionals, the US government, medical research centers, medical governmental and
non-governmental organizations, corporations, and pharmaceutical companies. The
different arrows in Figure 6.1 represent the various relationships between SGKC and its
partners. Pharmaceutical companies and corporations directly acted as ﬁnancial sponsors
to the organization, via cause-marketing campaigns, and as sponsors and participants at
events (i.e., Race for the Cure and global breast cancer summits).

In pursuing a global breast cancer advocacy agenda, SGKC partnered with the US
government, the Fred Hutchinson Cancer Research Center (FHCRC), and international
medical professionals. The partnership between SGKC and the US government led to the

creation of two hybrid breast cancer awareness and research programs, in Central and

139

South America and in the Middle East. The Breast Health Global Initiative (BHGI), a
hybridization of medical, advocacy, and corporate identities, was created out of the
partnership between SGKC and the FHCRC. This collaborative initiative in turn led to
the creation of international medical and advocacy breast cancer summits. Finally, SGKC
partnered with prominent international medical professionals, who facilitated the creation
of international SGKC afﬁliates that developed as hybrid medical/advocacy organizations
in a way that US afﬁliates typically did not.

SGKC also created the Course for the Cure advocacy training program, in which
local breast cancer advocates participate to learn SGKC advocacy strategies, including
how to host Race for the Cure (RF TC) events. In addition to participating in RF TC
events, local advocates also participated in the Global Breast Cancer Advocate Summit.
Finally, international medical professionals actively participate in running international
afﬁliates, RFTC events, and the Summit on lntemational Breast Health. The integral role
played by medical professionals, corporations, and pharmaceutical companies in
international RFTC events has introduced a hybrid form of advocacy, which, while

becoming commonplace in the US, is quite new in many countries.

140

Figure 6.1. SGKC’s Transnational Mixed Actor Coalition

 

 

 

 

 

 

 

 

 

 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

   
  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

“WI“ NGOs/Arlroater ”I (My. Gennarry,Puerto Rico) 1*—
the Cure - . '
(Wait I z i
m l l :
rm \ 1 r - l
C atlas
1[ .lRacelortlreCure . m I l
I
Dhlonntic Wm 1-..........-,,.. n.-- - . . ___. Mal 1.
America: andthe ’
Middloliast
Fred Hutdl'nsou
Canoe- Research
1 Cute
US —" siftiirien‘y Brustllulth , ‘
Government ““CUIE Globall ." 1' Medical
. , Gwanmartalantl
l Non-Governmental
Orgariutionr
Pha'mcedical Global Breast Cancer
Companies Summits ; National Cancer
Novartis ; Sunmit onlntennti
L— Johnsoo&lolmson Lil BreastHeaIth t—l.‘ American Career
AstraZeneca Society Internaional
PﬁzerOnoology Global Breast Cancer
Bristol-Myers Squibb Advocate Surmrit American Society of
_ Clinical Oncology
d
Financial Sponsorship Participation Creation Partnership
of in of between
ﬂ ——-—’ 'm‘mm' i7- H

 

These collaborations have enabled SGKC to create international RFTC events,
affiliates, advocacy training programs, and conferences. Through this transnational MAC,

SGKC is expanding its brand of biomedical breast cancer advocacy via hybrid initiatives

141

and events. These hybridizations diverge from past understandings of relationships
between advocacy organizations, governments, corporate sponsors, and the medical
community in which each maintained a clearly separate identity, but in which
governments, corporations, and/or the medical community provided ﬁnancial or
informational resources to advocacy organizations (McCarthy 1977). Increasingly,
scholars are recognizing the complex interrelationship between advocacy organizations
and corporations and the need to examine how advocacy organizations, corporations, and
other sectors of society are intertwined with one another (see, e. g., Yaziji 2009).

In the US, SGKC developed a brand of biomedical breast cancer advocacy,
facilitated by the founder’s corporate connections, that embraced a hybridization of
corporate/advocate initiatives and events, primarily through cause-related marketing
campaigns (McCormick 2006; King 2006). To expand globally SGKC developed a
transnational MAC that expands this hybrid model of advocacy by increasing SGKC’s
partnerships with medical professionals, medical research centers, the US government,
multinational corporations, and companies in the countries into and within which they are
expanding.

Partnering with Medical Professionals

In 1998, SGKC began considering global expansion. Susan Braun, President and CEO at
the time, began attending international breast health conferences looking for international
partners, particularly medical professionals specializing in breast cancer, who were
interested in developing a partnership to form international affiliates of the organization.

At one such meeting in Rome, Italy, Braun and a prominent Italian breast surgeon began

142

discussing the development of the ﬁrst international affiliate. As recalled by Francisco
Bacci, the founder of Komen Italia,
Actually I was very fortunate to run into Komen, just our roads crossed one on top
of the other back in 1998 when they started to look for international expansion.
The president and CEO of Komen came to Rome for a meeting that I was
organizing that brought together presidents or general secretaries of twenty-ﬁve
different national breast societies to present their work. And I work very much
myself with international collaboration particularly in the United States, so it
came out that many of the medical groups that they were [ﬁnancially] supporting
in the United States were groups which I had worked with, so kind of a special
feeling developed and that was really a very, very big luck in my life because
working with Komen has allowed me to improve a lot of the work that I am doing
in Italy and here in Rome.[Working with Komen has] just given me tools to
impact breast healthcare in Italy on a larger scale than I could have done on my
own. So I’m very, very grateful for this opportunity (Personal Interview, Rome,
Italy, October 16, 2007).
The positive interaction between Francisco Bacci and the President of SGKC at this
conference led to a partnership between SGKC and this Italian breast surgeon, who
recruited other breast surgeons and oncologists to bring the SGKC advocacy model to
Italy and form the ﬁrst SGKC international afﬁliate, Komen Italia. The founding of
Komen Italia demonstrates how from their inception international afﬁliates were hybrid
medical/advocacy organizations. In the US, breast cancer advocacy organizations,
including SGKC afﬁliates, are predominantly initiated by breast cancer patients,
relatives of people who have had breast cancer, and/or people who perceive themselves
as high-risk for the disease, as was the case with the Lansing, MI SGKC afﬁliate.
lntemational affiliates, on the other hand, were formed with medical professionals at the
outset.
The partnership between SGKC and the Italian medical professionals led to a
mutually beneﬁcial relationship: the leaders of SGKC found trusted partners with whom

it could globally expand the Komen brand of advocacy; the University Hospital within

143

which the founding breast surgeons and oncologists worked were able to construct a
breast cancer center within the hospital using funds raised through SGKC advocacy
techniques. The use of SGKC advocacy strategies proved beneﬁcial to the founding
doctors. Speciﬁcally, Komen Italia successfully campaigned to get a breast cancer
stamp, similar to the breast cancer stamp in the US, issued by the national postal service
(Figure 6.2). With the initial funds from the sale of the breast cancer stamp, the Catholic
University Hospital, in which the Komen Italia office is housed and the breast surgeons
who founded Komen Italia work, a center dedicated speciﬁcally to breast cancer was
constructed with the latest breast cancer screening and treatment equipment. The
founders of Komen Italia now work together in this new Center. Francisco Bacci
recalled the story of how this happened,

This [Center] was something that our university had planned to construct but it
was really only when we were able to raise additional funds to support the
university in doing this, and this was made possible through a breast cancer
stamp, similar to the one that was created in the United States. This was just a
perfect example of how we’ve looked at something that was very successful [in
the US] and strived to introduce it with the necessary adaptations in Italy. And so
[the construction of the breast cancer center] was really something very far in the
distance, nobody had a clue of how it could happen, but when you have a good
model, you have some additional chances to make changes happen. Eventually we
were able to convince the Italian postal system that this was a nice thing to do. It
was the ﬁrst time in history that there was a stamp that would collect money. We
asked the president of Italy to make, not a law, but to dictate how this money
eventually collected should be used and at our urging, he included a percentage
of this money to help the university to build this new center and so this has
happened, so this place where we are sitting now today is due to in this case to a
joint eﬂort between our university and Komen. We joined forces together to
convince the Italian postal system to make this stamp, and the stamp generated
money and part of this money was supposed to be spent for this center and so it
was. And also the rest of the money that was collected was used to support young
researchers, young scientists, to develop some research programs in top cancer
centers in Italy and in the United States (my emphasis, Personal Interview, Rome,
Italy, October 16, 2007).

144

Figure 6.2. US Breast Cancer Research Stamp and Italian Breast Cancer Stamp

 

     
    
    
 

 

 

 

 

 

’ .
’ d
o
o
O
i
o
O
O
o
I . v rrrrrrrr unuovvuu~¢vecn~
. ‘ . g. 5 IV“. S
e . ' ‘ I 21
1 ' : c’ r-
. ‘ . -" : '-
0 . 3
' 1 - c 5
O , :- O
P ‘ ' ’15- \C A
i : ; "Arm
1 4 : C‘- €0.60+€0.30
I z I g ‘ H: r . ' 'I- ... men-r n. 1.: w.»
o 1 . .. . -_ ._ ...,.
‘. I I . . . . - . . . I .4 'AuJJ11-.nu.uummAm-.
Source: US Postal Service, http://www nsps ’ ' htm; Komen

Italia, http://www.komen.it/iniziative.htm

The implementation of the breast cancer stamp and the funding of the breast cancer
center demonstrate how, through its global expansion, SGKC has become intricately tied
to medical professionals, who beneﬁt from the relationship. Komen Italia often serves the
interests of breast cancer patients by improving the resources of medical professionals.
The organization has a strong medical identity (see Chapter 7), which has merged with its
advocacy identity in that young doctors receiving training in breast surgery are now
introduced to SGKC during their medical training and often work on advocacy projects
with the organization. As Margarita Solice, a 26-year-old medical resident at the Catholic
University where Komen Italia is located, stated
I am very biased about Komen because I am like their daughter. I came to my
breast surgery rotation not knowing what to specialize in and now I am
specializing in breast surgery for sure. The advocacy they do is so wonderful and
makes you feel that you are not just being a doctor, but are doing extra good
things. So I love being a part of it and as a doctor, I can help with their events,

like doing screenings and exams, in ways that other volunteers cannot (Personal
Interview, Bologna, Italy, October 27, 2008).

145

Margarita’s comments exemplify the way in which medical and advocacy identities are
blurred by the collaboration between SGKC and breast health professionals in the
establishment of international afﬁliates.

The Puerto Rican affiliate was similarly established through a partnership
between breast health medical professionals and SGKC, at the urging of a breast cancer
survivor ﬁom the US who had relocated to Puerto Rico. As explained by Carmen Arollo,
a Komen Puerto Rico advocate, the ex-president and founder of Komen Puerto Rico was
a breast cancer survivor who knew about Komen from the time she lived in the States,
“so when she came down here she just got a group of doctors who helped her get all the
information for the application [to become an affiliate] and that’s how it all started”
(Personal Interview, San Juan, PR, September 12, 2007).22 Again, breast cancer surgeons
and oncologists were familiar with the SGKC advocacy model and were amenable to
bringing the organization to Puerto Rico to raise funds that could be allocated for medical
research and new equipment. The board of directors of Komen Puerto Rico, like that of
Komen Italia, consists of a combination of breast cancer survivors, surgeons and
oncologists who direct the focus of the organization (e.g., awareness, education,
fundraising, research) and have control over the allocation of the afﬁliate’s funds.23

Similar to the Puerto Rican case, a group of US expatriates, who had worked with
SGKC in the US, founded the German afﬁliate, Komen Deutschland. While I did not visit

this afﬁliate, Sara Friedman informed me that

 

22 The founder and ﬁrst president of Komen Puerto Rico was the daughter of a well-known man in the
medical insurance industry. He was the founder of a Puerto Rican insurance company. She was also in the
insurance business. The Senate of Puerto Rico granted her a special award for bringing SGKC to Puerto
Rico, advancing breast cancer awareness and education (Rios Santiago 2006).

23 The allocation of funds will be discussed in Chapter 8.

146

with the German affiliate, that began with a group of US expats who were there

and throughout time the affiliate has become much more, obviously, much more

German, with German staff members and it is really a German organization. It’s

really become their own, rather than started by a group of American expats and

continued to be that way (Telephone Interview, November 16, 2008).

While the German afﬁliate is now run by native Germans, like the other international
affiliates, the board of directors consists of a mixture of breast cancer survivors and
medical professionals specializing in breast cancer, who like medical professionals
working with SGKC in Puerto Rico and Italy, are likely beneﬁting from their
involvement with SGKC via increased funds for medical technology and research.

The development of SGKC international affiliates, therefore, entailed signiﬁcant
collaboration between US directors of SGKC and breast cancer surgeons and oncologists
in the affiliate locations, who took the lead in the formation of international afﬁliates.
Breast surgeons and oncologists continue to play a prominent role in the organization,
serving on their directorial boards and participating in events (see Chapter 7). Medical
professionals became trusted partners for SGKC, allowing the organization to create
affiliates internationally, expanding the SGKC brand of biomedical breast cancer
advocacy, increasing opportunities for ftmdraising, and solidifying the organization’s
reputation as a pioneer in breast cancer advocacy by being one of the ﬁrst organizations
to expand globally. At the same time, medical professionals beneﬁted from the
partnership by drawing more ﬁnancial resources to their medical practices, in the process
also increasing the public’s attention to breast cancer.

The partnership between SGKC and international medical professionals is a

hybridization of medical and advocacy organizational identities. Medical professionals

are playing a prominent role in an advocacy organization and participating in advocacy

147

 

 

 

events, utilizing their medical expertise.24 In the case of Komen Italia, the affiliate office
is physically located within a hospital, strongly associating the organization with the
medical profession. Young Italian breast cancer surgeons and oncologists learn about
SGKC during their medical training and may participate in advocacy events for the
organization. SGKC activities, such as RFTC, are hybridizations of both advocacy and
medical activities, in that in addition to the race, which raises awareness about breast
cancer and funds for medical research, medical professionals maintain a strong presence
at the events, providing breast health education, clinical exams and mammograms (see

Chapter 7).

Partnering with the US Government
After establishing these three international afﬁliates, SGKC moved away from the model

of international afﬁliates and began collaborating with the US government to create
initiatives in which SGKC would teach advocates in other countries about their brand of
biomedical breast cancer advocacy. Unlike many other transnational advocacy networks
and coalitions that situate themselves in opposition to neoliberal globalization, often
critical of the US government’s furthering of neoliberal policies, SGKC’s biomedical
breast cancer advocacy model provides an opportunity for partnership with the US
government in the interest of diplomacy. The US government potentially beneﬁts from
these diplomatic efforts by building positive relations with political regions where they
are otherwise in conﬂict and/or have political and economic interests such as in the
Middle East. As stated by Laura Bush (2006), in her comments regarding the partnership

to an audience of advocates from SGKC, executives from MD Anderson Cancer Center

 

2" I discuss the role of medical professionals in advocacy activities in detail in Chapter 7.

148

 

 

and Johns Hopkins Medical Center, and breast cancer specialists and advocates from
Saudi Arabia and the United Arab Emirates,

This is the ﬁrst major women’s health campaign in the Middle East, and the
United States is proud to be a part of it. The pain of losing a loved one to breast
cancer—and the joy of seeing a loved one triumph over it—are universal. By
confronting the challenge of breast cancer together, this partnership—which
represents the very best kind of public diplomacy—will also help build lasting
friendships between our countries. Most important, this partnership will help
women throughout the Middle East ﬁnd hope in a life free from breast cancer (my
emphasis).

Laura Bush’s comments demonstrate the attempt by the US government, in

partnering with SGKC, to improve its relationship with countries in the Middle East

 

through breast cancer advocacy, which had proven in the US to be a non-partisan “feel
good” cause that everyone can support (King 2006). In addition to beneﬁts to the US
government in terms of their international reputation, SGKC ﬁnancially beneﬁts from
this relationship since the partnership allows SGKC to expand its organization to many
new countries because the US State Department ﬁnances the majority of the expansion.
As Sara Friedman, a SGKC advocate with their international programs, explained,
With our international afﬁliates, we fund them from our headquarters. But with
the partnerships, and by these I’m referring to the US-Middle East Partnership
that we have for breast cancer research and awareness and the partnership of the
Americas, both of those, since they are managed by the US State Department and
Komen’s really an advocacy partner and MD Anderson is the lead medical
partner, they are largely ﬁnanced by the State Department, which is very nice for
us. We can have a strong presence in more locations without such a large
ﬁnancial expenditure (my emphasis, Telephone Interview, November 16, 2008).
The US government and SGKC have jointly established partnerships with the
Middle East and with Central and South America for breast cancer awareness and

research. According to Laura Bush, who has been actively involved in the diplomatic

events announcing these partnerships in Washington DC and establishing the partnerships

149

 

in Middle Eastern, Central and South American countries, “breast cancer does not respect
national boundaries, which is why people from every country must share their
knowledge, resources and experiences to protect women from this disease” (SGKC

2007)

US-Middle East Partnership for Breast Cancer Awareness and Research
An outgrowth of the US Department of State’s Ofﬁce of Public Diplomacy and Public

Affairs and the Middle East Partnership Initiative in collaboration with SGKC, the US-
Middle East Partnership for Breast Cancer Awareness and Research is touted as being
“the ﬁrst major women’s health campaign in that part of the world” (SGKC 2007).25 The
US Department of State’s Office of Public Diplomacy and Public Affairs and SGKC, in
collaboration with the MD Anderson Cancer Research Center and Johns Hopkins
Medical Center, developed the US-Middle East Partnership for Breast Cancer Awareness
and Research with the purported goal of making breast cancer a “global priority,” raising
awareness about breast cancer in the Middle East, and empowering women (SGKC
2007). As Nancy Brinker stated in her speech announcing the partnership in the United
Arab Emirates,

We have a very important role in this historic partnership. Over the past 25 years,

the Komen Foundation has been proud to work with women from every race,

ethnic group and religion—including Arab-American women in the United States

and Muslim women in Bosnia, Turkey, Egypt, the Palestinian territories, and
Pakistan (SGKC 2007).

 

2’ The US Department of State’s Middle East Partnership Initiative (MEPI) was founded in 2002, with
bipartisan support from Congress. “It has brought the resources, experience, and the determination of the
United States to bear in an effort to bolster the reform movement in the Middle East. MEPI has set in
motion more than 350 programs in 15 countries of the Middle East and in the Palestinian territories. In
four years, MEPI has underwritten a number of projects in the areas of education, economic growth, and
women’s empowerment and political participation. Its partners include local and international non-
governmental organizations, businesses, universities, international institutions, and, in some cases, the
governments of the regions themselves” (SGKC 2007).

150

In October 2006, SGKC Founder Nancy Brinker, and US Under-Secretary of
State for Public Diplomacy and Public Affairs, Karen Hughes, launched the US-Middle
East Partnership for Breast Cancer Awareness and Research (Figure 6.3). The
Partnership, initiated in the United Arab Emirates, was lauded by former First Lady
Laura Bush, who ﬁrst announced the partnership in Washington DC in June 2006, as
helping local UAE organizations to address [breast cancer mortality rates] by
uniting them with SGKC, which is the world’s largest and most progressive
grassroots network of breast cancer survivors and activists, along with the ﬁrst
class medical expertise of Johns Hopkins Medical lntemational (SGKC 2006).
The implementation of the partnership was facilitated by the pre—existing collaboration
between Sheika Fatima, a medical breast specialist in the UAE, and Johns Hopkins

lntemational. Through this collaboration, the UAE is “developing an Oncology Center of

Excellence that will include a women’s breast cancer center” (Bush 2006).

Figure 6.3. Announcement of the US-Middle East Partnership for Breast Cancer
Awareness and Research

 

Source: Press Release, Ofﬁce of the First Lady, June 12,2006. Available at
http: //www. ' ‘ L -... g ’20060612ﬁ61206sc-0043- -515h. htrnl

G

 

In developing this partnership, SGKC emphasized that while breast cancer

incidence in the Middle East is considerably lower than in the US, the mortality to

151

incidence ratio for breast cancer is higher than in the US and Europe. This means that
while a relatively small proportion of women in the Middle East will be diagnosed with
breast cancer in their lifetime, of the ones who do get breast cancer a relatively high
number will die from the disease (see Figure 6.4 for incidence and mortality rates for the
Middle East expansion countries as compared to the US). As stated by Nancy Brinker,
“The death rate is truly alarming. We know we can reduce that rate signiﬁcantly through
education and early detection” (SGKC 2007). The partnership does not involve creating
SGKC afﬁliates in the Middle East. Rather, the emphasis is on SGKCeled education and
training programs so that local organizations can learn from the SGKC advocacy model
and develop their own local awareness programs.

In March 2007, not too long after its implementation in the UAE, the US State
Department and SGKC expanded the partnership to Jordan. This partnership includes the
MD Anderson Cancer Center and the King Hussein Cancer Foundation and Cancer
Center. Just as in the UAE, the Jordan initiative did not formally establish SGKC
affiliates in the country. Rather, according to Hala Moddelmog, current SGKC President,
“through this partnership, breast cancer activists and health professionals in Jordan will
have access to experts from SGKC and MD Anderson as they work to develop programs

geared toward their communities” (SGKC 2007).

152

Figure 6.4. Age-Standardized Breast Cancer Rates for countries participating in the US-
Middle East Partnership for Breast Cancer Awareness and Research, World Standard (per
100,000)‘

 

United States oiAmerica ._ «we; .

 

 

0 2b 4b sh an 160 1&0

I Incidence
D Mortality

 

 

 

Source: IARC, Globocan 2002

‘An age-standardized rate (ASR) is a summary measure of a rate that a population would have if it had a
standard age structure. The most frequently used standard population is the World standard population. The
calculated incidence and mortality rates presented here are the World age standardized rates, which are
expressed as a rate per 100,000. The age-standardization technique is useful in making cross-country
comparisons (IARC Globocan 2002).

The most recent expansion of the partnership to Saudi Arabia in October 2007
was facilitated by the pre-existing collaboration between the King Fahad Medical City,
Saudi Arabia Cancer Society, and the University of Texas Nﬂ) Anderson Cancer Center
(Bush 2006). Dr. Suad Bin Amer, a Saudi Arabian breast surgeon, started the Breast
Cancer Research Unit at the King Faisal Specialist Hospital. “Like Nancy Brinker, Dr.
Suad was inspired by a patient she loved—her mother” (Bush 2006). This effort brought
together distinguished medical professionals and breast cancer awareness advocates ﬁ'om
Saudi Arabia and the US to “work collectively in the areas of awareness, research,
community outreach, and women’s empowerment” (SGKC 2007).

This partnership blurred the boundaries between the US government and SGKC,

as an advocacy organization. The expansion of SGKC’s brand of biomedical breast

153

cancer advocacy through a partnership with the US government, merged governmental
diplomacy and non-proﬁt advocacy. Furthermore, with Nancy Brinker shifting from her
position running SGKC to a US Ambassador and Laura Bush simultaneously speaking as
the First Lady of the United States and a breast cancer advocate working with SGKC, the
governmental/non-proﬁt identities became increasingly blurry. In addition to the
partnership between the US State Department and SGKC, this initiative also involved
prominent US medical centers, continuing to blur medical professional and advocate
identities.

Partnership for Breast Cancer Awareness and Research of the Americas

In addition to expanding the partnership to other Middle Eastern countries, SGKC and the
US State Department, in collaboration with the MD Anderson Cancer Research Center,
have also created a parallel partnership between the US and countries in Central and
South America. In late 2007, Laura Bush and Hala Moddelmog initiated the Partnership
for Breast Cancer Awareness and Research in the Americas. Brazil, Costa Rica, Mexico
and Panama currently constitute the participating countries. According to Hala
Moddelmog, this initiative “unites experts from the United States of America, Brazil,
Costa Rica, Mexico, and Panama to affect a measurable decrease in breast cancer
incidence and mortality in the Americas” (SGKC 2008).

Breast cancer incidence rates are fairly low in Mexico, Costa Rica and Panama
and are higher in Brazil, but still considerably lower than in the US (Figure 6.5). Rather
than addressing the particular reasons for expanding to these countries, Nancy Brinker
insisted that because “breast cancer is the leading cause of cancer-related death for

women worldwide. . ., it is crucial that women begin to take ownership of their health”

154

(SGKC 2007). The only case where Nancy Brinker addressed the speciﬁc incidence or
mortality rates in one of the Central or South American expansion countries was at the
launch of the Partnership in Brazil. There she stated that “Breast cancer. . .is the leading
cause of death for women in South America, and is the leading cause of death from
cancer among Brazilian women” (SGKC 2007). According to the World Health
Organization (2008), however, cardiovascular disease is the leading cause of death for
women in South America, and incidence rates of cervical and uterine cancer are more
pressing health issues for women than is breast cancer. Nevertheless, partnering with the
US State

Figure 6.5. Age-Standardized Breast Cancer Rates for participating countries in the

Partnership for Breast Cancer Awareness and Research in the Americas, World Standard
(per 100,000)

 

4 United States of America .
I Brazi .,
1 Costa Rica

Panama

 

I Mexico .

 

] o 20 40 so so 160 150

I Incidence
E'- Mortality

 

 

 

Source: IARC, Globocan 2002

Department allowed SGKC to pursue expansion into new countries to further extend the
reach of their brand of advocacy and enhance their organizational reputation as the

largest and most prominent breast cancer advocacy organization in the world.

155

The US-Middle East Partnership for Breast Cancer Awareness Research and the
Partnership for Breast Cancer Awareness and Research of the Americas exemplify the
blurring of boundaries between government and advocacy identities. The role of Nancy
Brinker in the US government and Laura Bush in SGKC demonstrates this blurring
between governmental and advocacy identities. The Partnerships themselves are
simultaneously forms of advocacy and diplomacy. MD Anderson Cancer Research
Center and Johns Hopkins also played signiﬁcant roles in brokering the expansion, given
the pre-existing relationships between medical professionals in the US and a number of
the expansion countries, thereby making these initiatives hybridizations of medical,

governmental, and advocacy identities.

Partnering with the Fred Hutchinson Cancer Research Center
In addition to partnering with the US government in their global expansion efforts, SGKC

and the Fred Hutchinson Cancer Research Center (F HCRC) jointly founded the Breast
Health Global Initiative (BHGI) in 2002. The mission of the BHGI is to “develop,
implement and study evidence-based, economically feasible, and culturally appropriate
guidelines for international breast health and cancer control for underdeveloped nations
to improve breast health outcomes” (BHGI 2008). Although the initiative was founded by
SGKC and FHCRC, it consists of partnerships between US governmental and non-
governmental health organizations, international health organizations, pharmaceutical
and medical equipment companies, and advocacy organizations (Table 6.1). According to
Sally Wellington who works with the BHGI, the various organizations involved do not
merely provide ﬁnancial resources for the initiative. Rather many of the organizations, as

indicated in Table 6.1, are on the BHGI steering committee (Telephone Interview,

156

September 5, 2008). When asked about the role of corporations in the initiative, which
are all pharmaceutical and medical equipment companies, Sally Wellington responded
that,

Well, they’re on our steering committee and they provide ﬁnancial resources but

they also provide their intellectual resources and we involve them in our steering

committee because we want their direction if we’re going down the right path

(Telephone Interview, September 5, 2008).

This statement exempliﬁes how the BHGI embraces a hybrid organizational structure, in
which all of the members of the steering committee, including pharmaceutical and
medical equipment companies, direct the organization. This is similar to representation
on the Board of Directors of SGKC and the Avon Foundation, but those boards consist
mainly of members with corporate backgrounds unrelated to the medical ﬁeld, whereas
the BHGI steering committee has more representation from pharmaceutical and medical
equipment companies.

The BHGI has initiated a number of global breast health summits, the most recent
of which was in Budapest, Hungary in September 2007. These summits, which target
medical professionals rather than lay advocates, but included advocacy representatives
from a number of countries, each had different focus areas: health care disparities in
2002, resource stratiﬁcation in 2005, and breast health guideline implementation in 2007

(BHGI 2008).“5 In 2007, in conjunction with the Global Summit on lntemational Breast

Health, SGKC hosted Ignite the Promise Global

 

26 The 2002 summit was held in Seattle, Washington. Panels of medical professionals ﬁ'om 17 countries
were brought together to discuss the creation of international guidelines to address early detection,
diagnosis and treatment of breast cancer in countries with limited health care resources. The 2005 summit
was held in Bethesda, Maryland. This summit consisted of 67 participants from 33 developed and
developing countries, including health care professionals, epidemiologists, advocates, sociologists,
economists, and representatives from health ministries and health organizations. This conference was
dedicated to reassessing the recommendations made at the ﬁrst summit. The guidelines developed at the
summit addressed: (1) early detection and access to care, (2) diagnosis and pathology, (3) breast cancer

157

Table 6.1. Founders, Partners, and Sponsors of the BHGI
Founding Organizations

Susan G. Komen for the Cure*

University of Washington Fred Hutchinson Cancer Research Center“
Global Summit Host Orgghation

American Society of Clinical Oncology“

Sustaining Scientiﬁc Organization Partner

National Cancer Institute, Ofﬁce of lntemational Affairs“
Sustaining Cogporate Sponsor

Pﬁzer Oncology“

Scientiﬁc Organization Partners

American Cancer Society*

Livestrong Lance Armstrong Foundation“

Corporate Partners

AstraZeneca*

Bristol-Myers Squibb Company*

Etlricon Endo-Surgery, Inc., a Johnson & Johnson Company“
Novartis

GE Healthcare*

Roche

Collaborating Organizations

Pan American Health Organization“

Ofﬁce on Women’s Health, National Cancer Institute
Office of Research on Women’s Health, National Institute of Health
Oncology Nursing Society"

American Society for Breast Disease“

Centers for Disease Control and Prevention“

Participating Orgaiizations

World Health Organization"

Breast Surgery International"

lntemational Union Against Cancer

International Network for Cancer Treatment and Research
lntemational Atomic Energy Agency of the United Nations"
International Society of Nurses in Cancer Care

lntemational Society of Breast Pathology

Middle East Cancer Consortium

World Society for Breast Health
Source: Report from the Breast Health Global Initiative (2008)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

treatment and allocation of resources, and (4) health care systems and public policy. The 2005
recommendations were stratiﬁed into 4 resource levels, which each consisted of recommendations in the
four areas, based on resource levels. The stratiﬁed resource levels consist of basic, limited, enhanced, and
maximum based on a country’s health care infrastructure and access to breast health detection, diagnosis
and treatment equipment. The most recent summit was held in Budapest, Hungary. One hundred
participants from 40 countries attended the summit to discuss the implementation of the resource-stratiﬁed
guidelines (BHGI 2009).

158

*These are also on the BHGI Steering Committee along with representatives from University of Texas MD
Anderson Cancer Research Center, Evanston Northwestern Healthcare, the European School of Oncology-
Italy, Latin American and Caribbean Society for Medical Oncology (SLACOM)-Argentina, and Breast
Surgery lntemational-Austria.

Breast Cancer Advocate Summit, the ﬁrst international breast cancer advocacy summit
bringing together advocates from over twenty-ﬁve countries (BHGI 2008). First Lady
Laura Bush and Dr. Klara Dobrev, wife of the Hungarian Prime Minister, served as
Honorary Co-Chairs of the event. While this summit focused on advocacy, many of the
advocates involved were also medical professionals specializing in breast cancer.

Although SGKC and the FHCRC founded the BHGI, they actually work in
separate, but complementary, ways in international activities. Based on their three
international breast health summits, F HCRC, through the BHGI, is creating “Learning
Laboratories,” starting in Ghana, where they have established strong ties to a group of
breast cancer doctors in order to implement their breast health guidelines on the ground.
At the same time, SGKC is creating breast cancer advocacy initiatives, via their Course
for the Cure training program, in these countries (Ghana, Romania, and Ukraine).

The BHGI, therefore, is a hybrid initiative, founded by an advocacy organization
and a medical research center. It is run by an even more diverse board, consisting of
representatives of medical research centers, advocacy organizations, US governmental
and non-governmental health organizations, international health organizations, and
pharmaceutical and medical technology corporations.

Course for the Cure: Training International Breast Cancer Advocates
As mentioned in Chapter 4, SGKC moved away from establishing international afﬁliates,
and instead has created global initiatives, implementing its Course for the Cure advocacy

tl‘aining program in partnership with the US Government in Middle Eastern and Central

159

 

 

and South American countries and in collaboration with the BHGI in Ghana, Romania,
the Ukraine, and soon in India. These initiatives involve the implementation of SGKC’s
Course for the Cure training program, which integrates key principles of SGKC’s
advocacy model, which the organization boasts has successfully built “the world’s largest
grassroots network of breast cancer survivors and activists ﬁghting to save lives,
empower people, ensure quality care for all and energize science to ﬁnd and deliver the
cure for breast cancer” (SGKC 2008). In implementing this training program, SGKC
partners with various groups including NGOs, governments, and healthcare centers in
each country. The Course for the Cure consists of ﬁve training modules that “capture the
methodology and best practices that led the organization to becoming the world’s largest
and most successful breast cancer advocacy group” (SGKC 2007). The modules include
community breast cancer assessment techniques, volunteer and organization
development, awareness and education, fundraising, and advocacy (SGKC 2007).

SGKC collaborates with experts from the Institute of lntemational Education
(IIE) to train global advocates.27 The IIE jointly developed the Course for the Cure to
train advocates in the selected countries in the SGKC breast cancer advocacy model. HE
is also responsible for providing program management, hiring and managing the ﬁeld
staff and monitoring the results. According to Sara Friedman, a SGKC advocate working

on international initiatives,

 

27 The Institute for lntemational Education is an independent non-proﬁt dedicated to international education
and training. One of IIE’s missions is building leadership skills and enhancing the capacity of individuals
and organizations to address local and global challenges. A number of ﬁnancial sponsors fund IIE’s
programs, including US private sector organizations (e.g., American Airlines, Kraft Foods lntemational),
US governmental agencies (e.g., Department of Energy, Department of State, Department of Defense),
foreign government agencies (e.g., Italian government, Chilean Ministry of Education), overseas private
sector organizations/intemational organizations (e.g., lntemational Monetary Fund, The World Bank), and
individuals and special funds (e.g., Rather Trust Fund) (2009).

160

We’re working very closely with IIE, their San Francisco Ofﬁce. And they are the
organization that actually manages Course for the Cure for Komen because
they’re such a leader in international education. And they work directly in our
selected countries. We have a program manager and a master trainer in each
country. And these people are in charge of utilizing Course for the Cure in
training people (Telephone Interview, November 16, 2008).
In describing the purpose of the Course for the Cure, Sara Friedman stated,
We’ve been working in conjunction with the State Department and BHGI to bring
what we are calling Course for the Cure to a select group of countries, as a pilot
program and this is a program in which we train individuals in the selected
countries who are working with speciﬁc partners that have been chosen. We’re
working with them to teach them about volunteerism and advocacy, fundraising,
all the components that they need in order to do their advocacy work on the
ground and to, you know, implement breast health and breast cancer programs
locally (Telephone Interview, November 16, 2008).
This model of global expansion allows SGKC to expand its brand of advocacy to an
increasing number of countries, through collaboration with the US government and the
BHGI as well as on the ground collaboration with local NGOs, healthcare centers, breast
cancer survivors and “others who are in a position to spread awareness to the general
population” (SGKC 2009). SGKC is never, therefore, expanding solely as an advocacy
organization. Rather it has expanded internationally through hybrid initiatives that have

blurred the boundaries between governmental, medical, and non-governmental sectors.

Partnering with Corporations and Pharmaceutical Companies
Finally, corporations, and speciﬁcally, but not exclusively, pharmaceutical and medical

technology and equipment companies have participated in SGKC’s international
expansion efforts. As with SGKC affiliates in the US, international afﬁliates actively
recruit corporate sponsors for their events, primarily the RF TC, which is the largest event
for all afﬁliates. According to Carmen Arollo, a Komen Puerto Rico advocate working on

soliciting corporate partnerships, Komen Puerto Rico sustains itself through fundraising

161

events, personal donations and corporate donations (Personal Interivew, San Juan, Puerto
Rico, September 12, 2007). These partnerships beneﬁt SGKC, as I discussed in Chapter
4, by ﬁnancially supporting the organization’s events and contributing funds to the
organization via cause-related marketing campaigns. Carmen Arollo explained that she
started recruiting corporate partners by asking companies that were already working with
SGKC in the US. She contacted Yoplait, a consistent partner of SGKC in the US. At the
time, Yoplait was not distributed in Puerto Rico, but in 2006 they expanded their
distribution to Puerto Rico and sponsored the RFTC in 2007. At the urging of Komen
Puerto Rico, Yoplait agreed to initiate the Save Lids, Save Lives cause-related marketing
campaign, which has existed in the US for years, to beneﬁt the Puerto Rican affiliate
(Carmen Arollo, Personal Interview, San Juan, Puerto Rico, September 12, 2007).
Komen Puerto Rico, therefore, acted as an impetus for Yoplait’s expansion to a new
market. The Save Lids, Save Lives campaign has also beneﬁted the image of the yogurt
brand in the US and has the potential to draw attention to the brand in Puerto Rico, as one
of the ﬁrst few breast cancer cause-related marketing campaigns. As in the US, these
corporate/advocate partnerships blur the boundaries between corporate and advocacy
identities, creating a hybrid corporate/advocate identity for the advocacy organization and
for the corporation. By visibly sponsoring SGKC and engaging in cause-related
marketing campaigns, corporations present themselves to consumers as more than
businesses simply interested in proﬁt, but as advocates supporting a cause. Similarly,
SGKC is a hybrid advocate/corporate organization, not simply operating as an non-

governmental organization, but, as discussed in Chapter 4, engaging in marketing

162

practices modeled after corporate strategies and including corporations as signiﬁcant
partners in the organization and in events.

Figure 6.6. Johnson & Johnson Presence at SGKC’s Race for the Cure, Bolo a, Italy
\ .

   

 

‘1. ‘o

. ‘ ' . \

1 ¥_\ . . . ‘1‘ I . g)
Source: Personal Photo taken on September 28, 2008, 2“' Annual Race for the Cure, Bologna, Italy

In addition to contributing ﬁnancially to lntemational affiliates and to speciﬁc
events, corporations, pharmaceutical companies, and medical technology and equipment
companies also maintain a physical presence at international RFTC events. For example,
Johnson & Johnson Medical, developer of MAMMOTOME Biopsy System, a minimally
invasive device that helps doctors diagnose breast cancer at its earliest stages, is an active
participant in Komen Italia RFTC events (Johnson & Johnson 2009) (Figure 6.6). At the
RFTC events, corporate sponsors, like Johnson & Johnson Medical, have a booth in
which representatives from the company give out literature regarding the company and
their commitment to the breast cancer cause. In the case of pharmaceutical, medical
technology and equipment sponsors, literature is often provided regarding the breast
cancer treatments or equipment that they develop to serve breast cancer patients or to
facilitate the early detection of breast cancer. Often sponsors, such as Johnson & Johnson

representatives in Italy, wear shirts distinct from the Race day shirts to stand apart and

163

announce their presence at the event. Johnson & Johnson gave out blue J & J balloons to
all of the children who stopped at the booth, which stood apart from the light pink
Neutrogena balloons, which were only distributed to breast cancer survivors; Neutrogena
was the official sponsor of the survivors.

Non-medical companies also sponsor and participate in events. These sponsors
have booths at the events and oﬁen sell cause-related marketing products at the events or
distribute samples of their products with their logo on it. For example, New Balance, a
sponsor of RFTC in Italy, used its booth to demonstrate the company’s commitment to
breast cancer by selling pink ribbon running shoes (Figure 6.7). A portion of the proceeds
from the sale of the shoes beneﬁt SGKC.

The partnership between SGKC and corporations therefore is not merely
ﬁnancial. Corporations participate in the events. The literature provided by the
corporations at events often merges a corporate (proﬁt-oriented) identity with an
advocate (support-oriented) identity. In closing ceremonies at RFTC events, corporations
are recognized by SGKC as signiﬁcant partners and committed advocates of “the cause,”
making corporations, more than “sponsors,” integral members of an advocacy

organization.

164

Figure 6.7. New Balance’s Booth (left) and Advertisement for Pink Ribbon Running
Shoes (right)

 

 

 

 

Source: Personal Photos taken on September 28, 2008, 2"d Annual Race for the Cure, Bologna, Italy

As I have demonstrated, SGKC has expanded internationally as the central
organization in an extensive transnational mixed actor coalition consisting of partnerships
with the US government, medical research centers, medical professionals, and
corporations. These partnerships have blurred the boundaries between the non-
govemmental/social movement sector and governmental, medical, and corporate sectors
of society. Because the US government, medical professionals, medical research centers,
and corporations did not simply provide ﬁnancial or informational resources to SGCK,
but instead served on boards with SGKC leaders, created joint initiatives, and participated
in events, these partnerships have led to a hybrid form of advocacy in which previously

separate sectors of society are joining forces.

165

 

 

AVON FOUNDATION: DEVELOPING A TRANSNATIONAL MAC
While the SGKC transnational MAC is deﬁned primarily by collaboration among SGKC,

the US government, medical professionals, cancer research centers, and corporations, the
transnational MAC created by the Avon Foundation is deﬁned by the hybridization of
Avon corporate and advocate identities, as well as collaboration with Novartis
Pharmaceuticals and NGOS. Based on my research, I constructed Figure 6.8 as a visual
representation of the Avon Foundation’s transnational MAC. As discussed in Chapter 4,
the Avon Company, a multinational cosmetics corporation, developed the Avon
Foundation, which established the Breast Cancer Crusade in 1992. The international
expansion of Avon’s biomedical breast cancer advocacy occurred through Avon’s
international corporate ofﬁces, in locations where the Company already operated, as
discussed in Chapter 4. These international ofﬁces house the Company and the

Foundation, creating a hybrid corporate/advocate organizational identity.

166

 

 

 

Figure 6.8. Avon Foundation’s Transnational Mixed Actor Coalition

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Avon Company
lntemational Ofﬁces
1 "‘ (Avon Company & Avon
1 / Foundation)
Avon v
Foundation
Representatives/ __
Professional ’
Advocates ;— ~
Walk Around
; the World for
Local Breast Cancer
Advocates local NGO

 

 

 

 

 

 

Events \

Local Medical
Breast . Professionals
Cancer Global Connection *
Survivor Ribbon Tour

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pharmaceutical
Companies

 

 

 

 

 

 

 

Financial Sponsorship Participation Creation Partnership
of in of between

 

Through the international ofﬁces, certain Avon representatives who were
previously working with fragrances or cosmetics are assigned to the Breast Cancer
Crusade. Once charged with the Breast Cancer Crusade, these representatives are
responsible for the promotion and sales of breast cancer-related products, ﬁnding local

women’s health NGOS to partner with for the Walk Around the World for Breast Cancer

167

‘ AK La.‘ _. _...7- TM.“
s

 

 

events, recruiting other Avon representatives to attend and participate in the events, and
selecting Avon representatives who are breast cancer survivors to participate in the
Global Connection Ribbon Tour. Avon representatives in charge of the Breast Cancer
Crusade select a local NGO with which to partner. Through this partnership, Avon
Foundation sponsors an NGO event, and Avon representatives participate in the event
and sell cause-related marketing products at the event. These local hybrid NGO/Avon
Foundation events constitute Avon’s WAWBC events. Additionally, from 2005 to 2008,
Avon Foundation partnered with Novartis Pharmaceuticals, jointly creating the Global
Connection Ribbon Tour. The Tour, which is part of the WAWBC events, consists of the
passing of a breast cancer ribbon from survivor to survivor around the world. Medical
professionals also participate in local NGO/Avon WAWBC events by providing breast
cancer screening as well as other health-related services in some cases.

Avon Foundation events have expanded globally, therefore, based on the
locations of Avon Company offices, with an increasing number of countries participating
in Avon Foundation breast cancer events throughout the 19903 and 20003. Avon
Foundation’s international breast cancer advocacy is a hybridization of
corporate/advocate identities. The expansion of Avon Foundation breast cancer advocacy
beneﬁts the company through its cause-related marketing campaign. By collaborating
with Novartis Pharmaceuticals, Avon Foundation was able to create the Global
Connection Ribbon Tour, spreading awareness about breast cancer and international
solidarity among breast cancer survivors, while simultaneously advertising Avon
Company as the “Company for Women” and Novartis Pharmaceuticals as a company that

cares about women. As stated previously regarding SGKC, these hybridizations and

168

Pm‘rr-"Tzl
. 3'.

 

collaborations diverge from past understandings of relationships between advocacy and
corporate social sectors. Instead of maintaining separate identities, the Avon Foundation
and the Avon Company, along with Novartis Pharmaceuticals represent a hybridization

of corporate/advocate identities, in which advocate and corporate identities are blurred.

Corporate Origins of lntemational Advocates
Unlike SGKC, in which US advocates are mostly women who currently have or have had

breast cancer, or who have been personally affected by breast cancer, and international
advocates who are mainly medical professionals and women who currently have or have
had breast cancer, the Avon Foundation advocates are company employees who have
been assigned to the breast cancer crusade as part of their job. For example, in Puerto
Rico, when asked how she became involved with the Avon Breast Cancer Crusade and
the Walk around the World for Breast Cancer (WAWBC) events, Gabriella Lopez, an
Avon representative answered, “I was in charge of fragrances last year, and this year I am
in charge of breast cancer” (Personal Interview, Caguas, Puerto Rico, September 14,
2007). The additional training involved to run the Avon Breast Cancer Crusade did not
consist of health advocacy information. Rather it entailed information about the new pink
products Avon was selling at the time to frmdraise for breast cancer awareness and
research. Moreover, the representative in charge of the Breast Cancer Crusade was placed
in charge of ﬁnding local organization(s) with which Avon could partner for WAWBC
events. Finally, Avon representatives responsible for the Breast Cancer Crusade were
charged with developing advertising campaigns, and selecting an Avon representative,

who was a breast cancer survivor, to participate in the Global Connection Ribbon Tour.

169

ii—.
a

 

The Avon staff of professional advocates promotes Avon as the “Company for
Women” in collaboration with local NGOS in expansion countries. The Breast Cancer
Crusade professional advocates choose a local breast cancer organization to partner with
for the WAWBC event. In many countries a breast cancer-speciﬁc NGO does not exist,
given that breast cancer is not a prominent health concern in all of the countries to which
Avon has expanded. In countries where a breast cancer-speciﬁc NGO does not exist,
Avon’s professional advocates choose a general women’s health or cancer organization
to partner with for the WAWBC event. Avon acts as the main sponsor of the local event.
Avon representatives are encouraged to attend the event, where they sell pink breast
cancer products, wear Avon shirts, which are distinct from other participants’ shirts, and
donate the funds raised to local organizations dedicated to improving women’s access to
breast cancer screening.

Therefore, the Avon Company, through the Avon Foundation, creates
“professional advocates” who are charged with organizing breast cancer advocacy events
in the company’s international locations. These professional advocates are not trained as
advocates and often have no personal connection to the issue of breast cancer, but are
nevertheless, presented by the company as “breast cancer advocates” at NGO events in
countries where the company has expanded. This demonstrates the hybridization of
corporate/advocate identities within the Avon Company, which nms the Avon
Foundation. The corporation actually “creates” advocates, who both promote breast
cancer awareness, by distributing breast cancer information along with pink Avon

products and running, walking and marching in breast cancer events, and advertise the

170

ll...

 

Avon Company by promoting the company to breast cancer advocates at local NGO

events as the “Company for Women.”

Participation of Medical Professionals
As at SGKC events, medical professionals often play a role at Avon-sponsored WAWBC

events. In contrast to SGKC, medical professionals do not participate directly in the Avon
Foundation. Rather, medical professionals from local medical associations, hospitals, or
cancer centers are asked to attend WAWBC events to provide free mammograms,
information on breast self-exams and clinical exams, and in some cases additional
general health information and screening. In Puerto Rico, for example, the Avon
Foundation sponsored and participated in Marcha Por Una Causa, Cancer de Seno
(Walk for a Cause: Breast Cancer), a Sociedad Americana del Cancer (American Cancer
Society, Puerto Rican Branch) event. Doctors from the Puerto Rican Medical Association
attended the event, providing breast and pelvic exams, taking participants’ blood
pressure, glucose level and weight and giving general health advice (Figure 6.9).

Fi- ure 6.9. Event artici cant being weighed by a medical staff volunteer

   
  

Source: Personal Photo taken at Marcha Por Una Causa, Yauco, Puerto Rico, October 6, 2008

171

 

 

Medical professionals, therefore, participate in Avon-sponsored events, but do not
collaborate with Avon Foundation in the same way that they do with SGKC. By
participating in advocacy events, however, medical and advocacy identities are often
blurred, as medical professionals are there to provide medical screening, while also
participating in the events and often speaking as breast cancer advocates at opening and

closing ceremonies.

Partnering with Novartis: Global Connection Ribbon Tour
From 2005 to 2008, Avon Foundation’s Walk Around the World for Breast Cancer events

consisted of the Global Connection Ribbon Tour (GCRT). According to the Avon
Foundation (2006),

WAWBC participating countries are linked by a Global Connection Ribbon Tour,

which serves as a unique grassroots, woman-to-woman connection. In the Global

Connection Ribbon Tour, a selected breast cancer survivor from each event

travels to another country to attend the next WAWBC event as an honored guest.

This visiting breast cancer survivor passes to a local breast cancer survivor a

unique “Connection Ribbon” as a symbol of shared hope and survivorship—an

oversized pink ribbon imprinted with “Thank You” in multiple languages.
In Figure 6.10, a visiting breast cancer survivor from Peru is passing the Global
Connection Ribbon to a local breast cancer survivor in Ecuador during the GCRT in
October 2007 (Avon 2007).

In addition to traveling to another country to pass along the ribbon, in October of
each year most of the women participating in the GCRT are brought to New York City
for the Avon Foundation’s Global Breast Cancer Survivors’ Day luncheon and the Avon
Walk for Breast Cancer-New York, the largest Avon walk event. At the Avon Walk in

New York City the international survivors are stationed in a special “cheering section”

and are recognized in the closing ceremony (Avon 2006).

172

 

Figure 6.10. Avon Ecuador’s Global Connection Ribbon Tour Event

 

Source: Avon Foundation, Walk Around the World for Breast Cancer, Countries, Ecuador,
http://wnlk “ ‘ " 5:25“ Pages... mi} g Sm..c._Ecuad

Each year, Novartis Oncology sponsors the Global Connection Ribbon Tour. At
the ribbon passing event in every country, a representative of Novartis Oncology is
present and speaks at the closing ceremony. At the 50th Anniversary celebration of Avon
Foundation in New York, before recognizing the international survivors brought to New
York through the partnership between the Avon Foundation and Novartis Oncology, Dr.
Diane Young, Head of Global Clinical Development for Novartis Oncology, stated that

Novartis is delighted to be a partner with Avon in its crusade against breast

cancer. This initiative will increase awareness of breast cancer, help provide

women with better access to the latest medical information on breast cancer and

celebrate survival (Avon 2005).

Through this partnership, Novartis has been able to gain exposure in over 40 countries.

Novartis “develops and markets patent-protected prescription drugs” for various medical

conditions, including breast cancer. Speciﬁcally, they developed F emara, which is used

173

for the treatment of postmenopausal women with hormone receptor positive breast cancer
(Novartis 2009).

The partnership between the Avon Foundation and Novartis pharmaceuticals is a
hybridization of corporate/advocate identities. Novartis pharmaceuticals is not simply
sponsoring the event, rather Novartis representatives are present at and participate in the
events. Through the partnership, a particular advocacy event, the Global Connection
Ribbon Tour, was created to celebrate survivors and connect breast cancer survivors from
different countries. In doing so, the Avon Company, through the Avon Foundation, as
well as Novartis Pharmaceuticals gain exposure among breast cancer advocates and

promote themselves as more than just companies; they are advocates as well.

Partnering with Local NGOs
Unlike SGKC international afﬁliates, which do not partner with local organizations in

presenting Race for the Cure events, the Avon Foundation partners with local NGOS,
sharing in local events and donating 100 percent of funds raised from their cause-related
marketing campaigns to the partnering organizations. Given that the Avon Foundation
has expanded globally based on the locations of the Avon Company’s international
offices, and not on whether or not countries are particularly afﬂicted by or actively
advocating against breast cancer, as mentioned earlier in the chapter, in some cases
NGOS speciﬁc to breast cancer do not exist. Because of this, the Avon Foundation
representatives in charge of the WAWBC events may choose to partner with a general
cancer society or women’s health organization. As shown in Table 6.2, the Avon

Foundation partners with a variety of NGOS ranging from international afﬁliates of the

174

American Cancer Society, as is the case in Puerto Rico, to transnational breast cancer
organizations, as is the case in Italy, to local cancer and breast cancer groups.

Through these partnerships, the partnering NGOS receive ﬁmding for their events
and often a lengthy fundraising commitment from the Avon Foundation. In Puerto Rico,
for example, the Avon Foundation donates all of the proceeds from sales of breast
cancer-related products to the Sociedad Americana del Cancer (SAC). These funds are
not a general donation to the SAC, but rather they are allocated to breast cancer-speciﬁc
projects. In Puerto Rico, the SAC has a mammogram program, in which uninsured
women can get a voucher, take it to their doctor, and receive a mammogram free of
charge. Through these partnerships between the Avon Foundation and NGOS, the Avon
Company gains positive exposure in its support for the breast cancer cause, leading to a
solidiﬁcation of the Company’s reputation as the “Company for Women” in their
increasingly proﬁtable international markets.

Table 6.2. A Selection of Avon Foundation’s Partnering NGOS“

 

 

 

 

 

 

 

 

 

 

 

 

Country NGOs

Multiple American Cancer Society

Countries

Argentina Liga Argentina de Lucha Contra el Cancer (Argentinean
League Against Cancer)

Australia YWCA Encore Program; Australian New Zealand Breast
Cancer Trials Group

Bosnia lntemational Women’s Club Sarajevo

Canada Healing Arts Environments; Canadian Breast Cancer
Research Alliance

Chile Arturo Lopez Perez Foundation

China China Cancer Foundation; China Women’s Development
Foundation; Conghua Women’s Association

Czech Republic Alliance of Czech Breast Cancer Associations

 

175

Table 6.2 (Continued)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dominican Republic Northern Cancer Patronage;
Dominican Cancer League

Ecuador SOLCA (Cancer NGO)

El Salvador Liga Nacional Contra e1 Cancer
(National League Against Cancer)

Estonia Estonia Cancer Union

France Odyssea

Germany Bavarian Cancer Society; Berlin
Breast Cancer Project

Greece Hellenic Anti-Cancer Association

Guatemala Liga Nacional Contra el Cancer

India Cancer Patients Aid Association

Italy Italian League Against Cancer,
Europa Donna (pan-European
organization)

Latvia Tree of Life

Macedonia Borka

Malaysia Breast Cancer Welfare Association

Mexico Grupo RETO; Casa de la Amistad
and Caras dc Esperanza (House of
Friendship and Faces of Hope)

Oman National Association for Cancer
Awareness

Poland Post Mastectomy Women’s Club
“Amazons”; Warsaw Breast
Cancer Survivor Society

Romania Renastra Foundation (Breast
Cancer NGO)

Spain Asociacion Espanola Contra el
Cancer (Spanish Association
Against Cancer)

UK Breakthrough Breast Cancer;
Crazy Hats Breast Cancer Apparel

 

 

 

Source: http://walk.avonfoundation.org/site/PageServer?pagename=WorldWalk_Main

‘For some countries, Avon Foundation just lists “local NGOS” and for others, the organization did not
specify NGO partners. This table consists of all of the partnering NGOS that I was able to identify via the
Avon Foundation website as of May 2009.

CHAPTER SUMMARY
In this chapter I have argued that SGKC and the Avon Foundation have expanded

globally separately, but similarly, in creating transnational mixed actor coalitions. The

SGKC mixed actor coalition is more extensive than the Avon Foundation’s MAC, in that

176

it encompasses extensive partnerships among SGKC, the US government, medical
professionals, medical centers, and corporations. The Avon Foundation, on the other
hand, was created through a corporation, giving it a unique corporate/advocate identity
ﬁom its inception. Through these mixed actor coalitions, SGKC and the Avon
Foundation have expanded biomedical breast cancer advocacy globally. Rather than
expanding based on the need for breast cancer advocacy in particular countries, SGKC
expanded based on relationships with trusted medical professional partners and the US
government’s goals in creating the breast cancer initiatives. Avon Foundation, on the
other hand, expanded according to the locations of Avon Company ofﬁces, but also not
with regard to particular breast cancer advocacy needs in particular countries. The MACS
exemplify a blurring of the boundaries between advocate, corporate, governmental, and

medical identities, which will be further explored in Chapters 7 and 8.

177

CHAPTER 7

THE GLOBAL EXPANSION OF PROCESSES OF BIOMEDICALIZATION VIA
BIOMEDICAL BREAST CANCER EVENTS, CAMPAIGNS, AND PROGRAMS

In this chapter I draw on my ﬁndings regarding how forms of biomedical breast cancer
advocacy have been incorporated into, and adapted to, other political and cultural
contexts to argue that the diffusion of biomedical breast cancer advocacy events,
campaigns and programs are furthering processes of biomedicalization globally. With
only minor cultural and political adaptations, SGKC and Avon Foundation events,
campaigns and programs in other countries are strikingly similar to their advocacy
activities in the US. By raising awareness about early detection and disseminating
medical information, biomedical breast cancer organizations are promoting surveillance
medicine and creating new at-risk identities among women across the globe. Biomedical
breast cancer advocacy organizations are playing a signiﬁcant role in establishing a
biomedical understanding of breast cancer outside of the US by engaging in awareness-
raising activities and disseminating medical information about breast cancer. The focus of
SGKC and Avon Foundation events, campaigns, and programs is twofold: raising
awareness and raising funds. This chapter addresses the former, and Chapter 8 addresses
the latter.

In this chapter, I ﬁrst discuss the discourse of awareness, early detection, and
individual responsibility promoted by biomedical breast cancer advocacy organizations
through their global events, campaigns, and programs. Then I present the various ways in
which globally expanding biomedical breast cancer organizations are disseminating
medical information about breast cancer. Next, I discuss the promotion of surveillance

medicine by these organizations. Finally, I explore the creation of new at-risk identities.

178

RAISING AWARENESS: THE IMPORTANCE OF EARLY DETECTION

The similarities among biomedical breast cancer advocacy events in the US, Puerto Rico,
and Italy far exceed the differences. While the Avon Foundation has held different types
of events throughout the world ranging from ubiquitous walks and runs, relatively
commonplace press conferences, concerts, fashion shows, balloon releases, and unique
mountain climbs and motorcycle tours, all of the events focus on raising awareness and
raising funds. Similarly, SGKC’s Race for the Cure and similar events may be slightly
altered in terms of cultural content (e.g., an Italian band performed before the Race in
Bologna, Italy; Salsa for the Cure event in Puerto Rico); nevertheless the focus on raising
awareness about breast cancer remains consistent. In this section, I discuss the global
proliferation of “raising awareness” through biomedical breast cancer advocacy events,
campaigns, and programs, arguing that through these activities, SGKC and the Avon
Foundation are introducing and promoting a biomedical discourse regarding breast
cancer, speciﬁcally with regard to the discourse of early detection and individual
responsibility for monitoring one’s bodily health.

The notion of “awareness,” closely associated with breast cancer in the US, is
now being introduced and promoted in a number of countries by biomedical breast cancer
advocacy organizations. Awareness is promoted in ever-proliferating forms of events,
campaigns and programs. “The word about breast cancer even made it to the top of
Kilimanjaro as Avon South Africa staff headed to the top of the mountain clothed in Kiss
Goodbye to Breast Cancer shirts, spreading awareness with each step they climbed”
(Avon Foundation 2007). In Puerto Rico, SGKC has created an awareness campaign

based on using pink, the signature color of breast cancer awareness, to engage in any type

179

of “awareness-raising” activity. According to Carina Candall, a Komen Puerto Rico

advocate,

We have an event that we set up last year and it’s not on any speciﬁc date, any
day you pick, any day during the month of October, and either you do a walk, you
can light a building in the color pink, you can just light candles, you can wear
pink, something, anything, to create awareness. So we promote that in different
municipalities all around the island (Personal Interview, San Juan, Puerto Rico,
September 12, 2007).

In Romania, in 2006, Avon held “The Pink March” as part of their breast cancer

educational campaign. According to Avon Romania, this campaign was

aimed at reaching women in common locations such as subway stations, movie
theaters and hair salons. Subway and movie theater chairs were painted pink, and
messages of the importance of early diagnosis and treatment appeared on
television shows and in magazines (Avon Foundation 2007).

Since the Avon Foundation and SGKC began expanding globally, the number of these
types of awareness—raising events increases each year.

In her discussion of breast cancer philanthropy, as she refers to biomedical breast
cancer advocacy, Samantha King (2006, 95) presents the following quandary regarding
“awareness,”

What exactly does “awareness” mean in the context of breast cancer, and what is

it that consumers are being asked to gain “awareness” of? When Avon campaigns

do venture into speciﬁcs, awareness usually means preaching the beneﬁts of early
detection through mammograms. Although this approach might prompt women to
discover if they already have breast cancer, this selective brand of awareness asks
women to take personal responsibility for fending off the disease, while ignoring
more difficult questions related to what might be done to stop it at its source, or
for that matter, to treat it once those underserved women whom Avon claims to
assist receive a positive diagnosis.

Through their global expansion, SGKC and the Avon Foundation continue to promote

this same message of awareness, early detection and individual responsibility for one’s

180

.m.
’4..- -.
It

.A._ .

 

health. As stated by Hala Moddelmog, president and CEO of SGKC, regarding a breast

cancer initiative in the Bahamas,

Research has shown that too many Bahamian women are dying of breast cancer
because of lack of awareness and lack of access to early detection and treatment.
Fortunately, organizations like Susan G. Komen for the Cure, the Cancer Society
of the Bahamas and the Bahamas Breast Cancer Initiative have pledged to work
together to raise awareness and tackle these issues, so that together we can help
save lives here in the Bahamas (SGKC 2008).

Even though raising awareness is often mentioned along with lack of access to detection
and treatment due to lack of healthcare coverage, the relative absence of hospitals or
medical centers equipped to handle breast cancer detection and treatment effectively, or a
combination of the two, SGKC and the Avon Foundation focus their efforts on raising
awareness and stressing the importance of early detection, emphasizing the need for
women to be responsible for their breast health. For example, Annetta Hewko, SGKC’s
vice president of international programs, stated that the goal in establishing the breast
cancer awareness and research initiative in the Americas was “to educate and empower
women in the Americas to take charge of their breast health” (SGKC 2008). By being
aware of their breast cancer risk, performing self-exams, and routinely being screened by
a physician in order to detect any cancer at its earliest stage, Hewko implies, women will
have the ability to “take charge” of their breast health, without consideration of access to
healthcare services. Similarly, when asked about the main goal of Komen Italia, Rosa
Valentino, an advocate with the organization, responded,
to promote the prevention, I mean early detection, because I think that from
personal experience my mom she was lucky because she was 44 and she went to
the doctor for a normal check and he discovered she had a lump and it was a very
aggressive cancer and so. . .but I mean my mom she has a degree, she studied
hard, I mean she lives in, we live in Venice so it’s not a little village but she
personally at 44 she didn’t have any mammography before so I mean that, it’s

something that we have to promote, the detection and the prevention is the thing
we have to do and to promote in general I mean I think that is our principle goal.

 

181

Although Rosa Valentino notes the importance of early detection based on her mother’s
experience with breast cancer at the age of 44, it is not clear how much earlier her mother
would have detected her breast cancer even if she had a greater level of awareness given
that national healthcare coverage in Italy provides women with free mammographic
screening biannually only between the ages of 50 and 69. It is not surprising, therefore,
that her mother had not previously had a mammogram. Nevertheless, Valentino asserts
that the main goal of Komen Italia is to increase awareness, with no mention of extending
the age range for breast cancer screening covered by the national healthcare plan.28

While many Italian women, at least many urban Italian women, had been exposed
to breast cancer awareness messages prior to the arrival of SGKC and the Avon
Foundation through other breast cancer advocacy organizations, such as Europa Donna,
for many women in other countries, this form of “awareness advocacy” is being
introduced for the ﬁrst time by SGKC and the Avon Foundation. According to the Avon
Foundation,

The inaugural 2005 WAWBC series launched in 35 countries and attracted over

87,000 participants, creating the ﬁrst awareness events of their kind in many

regions. The need for continued awareness of breast cancer is great (my emphasis,

Avon Foundation 2006).
Similarly, the following excerpt from an Avon press release describes the passing of the

Global Connection Ribbon from a breast cancer survivor from the UK to a survivor in

Ireland,

 

2" This is particularly signiﬁcant because another breast cancer advocacy organization in Italy, Europa
Donna, petitions at the national and international level to increase the age range for breast cancer screening
covered by national health plans as well as making sure that there is a standard level of breast cancer
detection and treatment throughout Italy, given that access to quality care is often limited to urban areas.

182

 

Visiting survivor from the United Kingdom, Ann McGee, passed on the Global
Connection Ribbon to local survivor Bernie Weir. The passing of the Global
Connection Ribbon marked one of the ﬁrst times that a woman in Ireland stood
publicly to be recognized as a breast cancer survivor (my emphasis, Avon
Foundation 2006).
Members of these organizations argue that public events focusing on awareness are what
is needed globally to reduce the rising rate of breast cancer. According to Charles
Bradley, a founding member of the BHGI,

awareness is inappropriately low in low- and middle-income countries and it used

to be that way here [in the US] that people wouldn’t say the word “breast” or the

word “cancer” in public and you would talk about a “woman’s diseases.” I mean
being able to have races where people are running with pink hats on actually is

very important for early detection (Telephone Interview, October 21 , 2008).

The raising of awareness about breast cancer and the public advocacy events where
breast cancer survivors are recognized, therefore, are actually important precursors to
early detection according to Charles Bradley.

While ubiquitous in the US, these events are often reaching audiences of women
who have not previously been exposed to messages about breast cancer or to this form of
advocacy. While the form of awareness advocacy and the message of awareness, early
detection and individual responsibility remain consistent, events are often adapted to
cultural preferences, locations, and speciﬁc breast cancer risk information. For example,

On October 21, 2005, Avon China made history as the ﬁrst enterprise to hold a

social charity event at the Great Wall. Avon China partnered with the China

Cancer Research Fund to launch the Avon China Walk Along the Great Wall for

Breast Cancer at the ﬁrst gate of the Great Wall in J iayuguan City in Western

China. More than 300 participants walked the Great Pink Wall and 2,000 homing

pigeons were set free (Avon Foundation 2007).

By naming their WAWBC event, Walk Along the Great Wall for Breast Cancer, Avon

China incorporated a culturally signiﬁcant location into an unfamiliar type of event,

making it uniquely Chinese. At Marcha Por Una Causa: Cancer de Seno, in Yauco,

183

Puerto Rico, the message of awareness, early detection, and individual responsibility was
repeated every twenty minutes during the two-hour walk. A man inside a truck leading
the walk through Yauco shouted the message, which boomed out of the loudspeakers on
top of the truck (Figure 7.1).29 The message repeated was

Marcha por una causa, cancer de seno, dos mil ocho,

La esperanza comienza conmigo

Es muy importante, el autoexarnin y muy importante el deteccion temprano

Y recordamos que una de cada trece mujeres hoy en Puerto Rico encontrar cancer

de seno en qualquier ano de su vida. (F ieldnotes, Yauco, Puerto Rico, October 4,

2008).30
By citing the breast cancer risk statistic for Puerto Rico, the message was tailored to the
speciﬁc audience, while otherwise remaining consistent in terms of promoting awareness

and the importance of self-exams and mammography for early detection.

Figure 7.1. Marcha Por Una Causa: Cancer de Seno event

 

 

 

 

 

Source: Personal Photo, Yauco, Puerto Rico, October 4, 2008

 

29 Having a truck with loudspeakers leading a march is very common in Puerto Rican political rallies. This
form of political rally was adapted for this breast cancer awareness walk.

3° In English, the message is Walk for a Cause: Breast Cancer, 2008. Hope begins with me. It is very
important, the self-exam and early detection. And remember that today one out of every thirteen women in
Puerto Rico will get breast cancer at some point in her life.

184

In addition to their events, SGKC and the Avon Foundation seek media attention
in order to reach an even larger audience with the message of breast cancer awareness.
After their 2005 5K walk for breast cancer, Avon France noted that “the event was
covered by more than 30 media outlets helping to spread awareness and the important
message of early detection” (Avon Foundation 2007). Similarly, the Smile Walks, Avon
Japan’s breast cancer events held in Tokyo and Kagoshima in 2005, received extensive
media coverage, “further spreading the important message of early detection and helping
to break the stigma of breast cancer in Japan” (Avon Foundation 2007).

By introducing their events, campaigns and programs to an increasing number of
countries, SGKC and the Avon Foundation are expanding a particular brand of health
advocacy, namely “awareness advocacy,” as well as promoting a message of breast
cancer awareness, early detection, and individual responsibility for one’s health. These
messages are intended to produce change, not in healthcare structures, but in individual’s
health behaviors. While the events, campaigns, and programs are slightly altered for
cultural or political context in some cases, the message remains consistent. Women are
encouraged to “take charge” of their breast health, and these organizations are the ones
telling them how to do so. To be a responsible woman, one must regularly conduct breast
self-exams and seek clinical exams and mammograms when one reaches a certain age,

and regularly from then on.

ADVOCACY ORGANIZATIONS AS DISSEMINATORS OF MEDICAL
INFORMATION

In addition to being promoters of the message of awareness about early detection and
individual responsibility, biomedical breast cancer advocacy organizations are also

providers of medical information. As discussed by Clarke and her colleagues (2005, 450)

185

processes of biomedicalization have transformed information, knowledge production, and
distribution of medical information. Information about health and illness “is proliferating
in all kinds of media; especially newspapers, on the intemet, in magazines, and through
direct-to-consumer prescription drug advertising” (Clarke et al. 2005, 450). Furthermore,
Clarke and her colleagues (2005, 450) argue that there are multiple sources creating and
distributing health-related information and “non-expert” individuals are increasingly
expected to navigate and make sense of various health-related messages. Finally,
according to Clarke and her colleagues (2005, 450), while the proliferation of sources of
information, knowledge production and distribution has implications for democratizing
biomedicine, the interests of the pharmaceutical industry still predominate.

Although Clarke and her colleagues (2005) discuss this shift toward the
proliferation of health-related information, they do not directly address health advocacy
organizations. My ﬁndings indicate that globally expanding biomedical breast cancer
advocacy organizations are signiﬁcant sources of breast cancer-related health
information. Given that direct-to-consumer pharmaceutical advertising is currently legal
only in the US and New Zealand, most people are not exposed to medical information
directly by pharmaceutical companies. Additionally, because biomedical breast cancer
advocacy organizations are expanding to many countries where breast cancer is not a
health priority, public breast cancer-related health messages were often very limited or
non-existent prior to the arrival of these organizations (WHO 2008).

Both SGKC and the Avon Foundation disseminate medical information about

breast cancer through their respective events, campaigns and programs. One of the main

186

ways that both organizations do this is through the distribution of educational materials.
According to Sara Friedman, a SGKC advocate with their international programs,

Even with people [from other countries] who aren’t looking for collaboration or
want to be an affiliate or hold a Race for the Cure, people will call in, you know,
wanting educational materials or they’re holding an event in some location and
want materials translated into another language and you know it’s just those sorts
of inquiries we receive quite frequently and depending on where they are and
what they’re looking for sometimes we may have access to something and we can
send it directly to them or, you know, we’ll send them to komen.org where we
have a lot of our educational materials that can be printed out, including our BSE
[breast self exam] cards and just all of those types of you know, informative
pieces and very basic information that we want people to be able to have
(Telephone Interview, November 16, 2008).

All SGKC Affiliates have these educational materials at their ofﬁces and distribute them
at Race for the Cure and other events. Additionally, as stated by Sara Friedman,
organizations and individuals not afﬁliated with SGKC also have access to its educational
materials. In addition to educational materials available on their website, SGKC also
translates all of their materials for affiliate and Course for the Cure locations and allows
other organizations to translate educational materials for distribution as well. As Sara
Friedman indicated,
We do allow people to translate our materials into other languages. They simply
have to just let us know what they’d like to do and we have them ﬁll out a very
basic form and we provide them with a version that they can make edits to and
you know, work right in with, using our template and all that and we just simply
ask that they provide us back with a translation whenever they’re ﬁnished with it
so we can share that information. Because I think one thing that Komen, we feel
very strongly about, is the idea that we share what we know and that everyone
does not have, you don’t have to recreate the wheel. We want to save people time
(Telephone Interview, November 16, 2008).

In Figure 7.2, SGKC’s breast self-examination (BSE) cards are shown in Spanish and

English. The information is exactly the same in Spanish and English.

187

 

 

Figure 7. 2. Breast Self- Examination Cards 1n Spanish and English

SPAN-SH

 

Sr miter 3). o
awn-urns la- Tiff/i l1

   

Pasos para el
Autoexamen del Seno

Steps to Breast
Self- Examination

‘ l I .A / .‘IT‘IS N ~ A, "18551 ..........................................................................................

 

 

.a. was .. u. , .
ya ,0 ,ene 3 .egg), W ' ' ., w . t . me“. Just as your period ends (or at the same time each month
buscanoc Cua' ouier cambio lriorme mmediatamenre coalouer cambto .f you do rot have periods). check for any change in the

a su ooctor o enfermera VISIte requiem“? 3‘ GOC‘O' 9335115 normal look or feel of your breasts Report any changes to
exonenes d9 '05 sen-35 Y magma 50”” '3 Willem your doctor or nurse Go for regular breast exams and ask

Paso 1: Acostada about a mammogram.

- FI|CSC si sieme unit bolita dun, la piel més gruesa o ,7.“ «,1 ,
cnalquiaeambioen a
l A. .J.

‘4]

Step I: Lying Down

' Lie down on your back with a pillow under your
right shoulder

'Usediepadsofthethreemiddleﬁngerson yourleft

cltciido del seno.

. r
y pong: cl brazo derechodehajo de la abcza
Wm la mano irquierda extendida, examinese con la
yerna de los dedos, usando los ms dedos del medic

 

 

. Examines: haamdo “presion leve, odemrada y ﬁrme hand. to Chick your "31“ breast
I
u'rmlares circle without lifting your fingers off the skin
- Examines: dc arriba hacia abaio

Busque cm 105 err rods cl' rm del seno amba y ' Follow an up and down pattern
abajo del cuello lclavicula) y en lamla
- Repitz cstos pesos en el seno nquierdu

' Feel for changes In your breast, above and below
your collarbone and or your armpit

' Repeat on your left breast using your right hand

 

 

 

 

 

 

Mmmmmmnm
conlasmllmmil These steps mayberepeawd' while bathing or
Paso 2: Frente al Espejo ’hwmsmw
--- ' “ Step 2: In Front of the Mirror
01mm ms”.
”Wmlémﬂd'i FR anule Lmkfwmydrangahomnomdlnspeayour
' " ' r whim-.5. breastsinfomsteps:
lnnonnaL hmdnesussmosmcllmm 0 Hold arms at your side
- Con los brazossueltos a loslados desu cucrpu
' Hold arms over your head

' Con las manos sobre la cabeza

e r
para ﬂexionar los miisculos del pecbo

- En la misma position, inclincse un poco hacia delante

, I ' Press your hands on your hips and tighten your
chest muscles

' Bend forward with your hands on your hips

   

Para mi: ‘ ' '- ': “ml .1: l... .. ‘ ‘ de seno.
llame sin costo alguno a la l3 nea Nacional Komen de Ayuda sobre el
Cuidadc de los Senos o visrtenos en lnterne: en www. komen org

For more information about breast health or breast cancer,
please visit our website or call our Breast Care Helpline.

mummy 1-800 I’M AWARE mkomenorg 1-800 I'M AWARE
(E~800«462-9273) (LEGO-4629273)
‘15? V'l‘bl!‘ Mil-ﬂ ’Mcd Mm!“ nun?- Kmarry‘ v'LJl'clsmlrI “‘61.!

m.
.
InlmmnlrS-‘J.W5'UIF\ i’J- ‘1'urwvlbllmmlrmuuulu-J?SP ml

enrmmrmmmniwkomwu‘
.4-- c, -_«~..

‘ \.

DENWOﬂSODNuNImeMﬁAuM-VWI
J. ‘\ '\. x. \

 

 

 

 

Source: Komen Puerto Rico, educational material, 2008

188

Figure 7.3 is an educational handout created by SGKC. This handout is available
at the Komen Puerto Rico ofﬁce and was distributed at Komen events in Puerto Rico. The
handout provides information about the sizes of tumors that can be discovered by
mammograms and breast self-exams, comparing the tumor sizes to common coins. The
purpose of the handout is to demonstrate that yearly mammograms lead to the earliest
detection of breast tumors, ﬁnding them at a very small size because previous
mammographic images are used for comparison. The next larger size represents the
typical size of a tumor that can be found through an initial mammogram. The second to
largest size tumor is the size that a woman performing regular self-exams would likely be
able to detect on her own. Finally, the largest tumor, equivalent to the size of a half dollar
coin, is what a woman who does not perform monthly self-exams or have regular
mammograms may detect accidentally. This material emphasizes the importance of early
detection through regular mammographic screening.

Similarly, the Avon Foundation has a Breast Health Resource Guide (Figure 7.4)
that is included with all purchases of Breast Cancer Crusade products from their
brochure. Although the resource guide shown is in English, the brochure is translated into
a number of different languages and is distributed in all countries where Breast Cancer
Crusade products are sold. The resource guide is an eight-page pamphlet that includes
general breast health and breast cancer information, a glossary of relevant terms (e.g.,
biopsy, mastectomy), a list of organizational resources, information about the Avon
Breast Cancer Crusade, and a form to make a tax-deducible donation to the Avon
Foundation. The excerpt from the resource guide in Figure 7.4 shows the medical

information that is distributed with the purchase of pink ribbon products from Avon. The

189

guide includes a list of symptoms of breast cancer that women should be aware of and
look for, information about breast cancer risk, and ﬁnally information about early
detection through mammograms, clinical exams and self-exams.

Figure 7.3. Educational Material Distributed by Komen Puerto Rico

 

Mamografl'a

 

Tamaﬁo de los tumores que se detectan mediante
la mamografl’a y el autoexamen del seno.

escala en pulgadas

- — v
En comparacuon con las monedas 9

' m7]f‘TT'l"f'T"il ll’l ‘l'l'i ‘I'TT‘l Vii‘T‘V’YT
de uso corhun. O 1 2 l S

3 4
escala en centimetres

Tamaﬁo promcdio de un w

tumor que se derecta por
medio dc mamograﬁas
anuales cuando existen placas
anteriorcs para comparar.

Tamaﬁo promcdio de
un tumor que se dctccta
en una mamografia inicial.

 

Tamaﬁo promedio de

un tumor que la mujer
puede detectar si practica
e1 autoexamen del seno
con rcgularidad.

 

Tamaﬁo promedio dc
un rumor detectado
accidentalrnente.

 

 

 

 

Source: Komen Puerto Rico, educational materials, 2008

The Avon Foundation often cites the “fact,” based on anecdotal accounts, that its
educational material is directly leading to early detection, particularly in countries where

other informational resources about breast cancer are not readily available. For example,

190

at the WAWBC Global Connection Ribbon Tour events in Brazil in 2005, Maria, a young
Brazilian breast cancer survivor, accepted the connection ribbon from a survivor from
another country. According to the Avon Foundation, “At the age of 29, Maria found a
lump in her breast after reading an Avon breast cancer awareness brochure” (Avon
Foundation 2007). In this way, the Avon Foundation demonstrates that it is ﬁlling a gap
in breast cancer knowledge through the distribution of its resource guide, thereby
changing individual behavior and leading to breast cancer detection.

Beginning in 2009, in addition to the current resource guide, the Avon Foundation
plans to distribute SGKC breast health information. According to Marta Munoz, a
representative of Avon Puerto Rico, Avon will be including SGKC informational
resources because,

They have very, very, very good instruments in education. And that’s going to be

additional to the resource guide. We also serve the Caribbean. So we always do

everything in Spanish and English. The same brochure [of products] we have also
in English and Spanish and the same thing with the resource guide (Personal

Interview, Caguas, Puerto Rico, September 13, 2007).

In addition to educational pamphlets, SGKC and Avon Foundation advocates
engage in educational campaigns and programs in which biomedical breast cancer
advocates lecture or give seminars related to breast health. For example, Margarita
Solice, an advocate with Komen Italia and a breast surgeon, described a joint high school
educational program co-sponsored by Komen Italia and the Ministry of Education. For
the past ﬁve years medical professionals, like herself, working with SGKC visit high
schools to “teach young people about breast cancer and basically just try to change the

culture of silence around breast cancer, which is a big problem in Italy” (Personal

Interview, Bologna, Italy, October 27, 2008).

191

Figure 7.4. Excerpt from Avon Foundation’s Breast Health Resource Guide

Symptoms, abnormalities and changes

Early breast cancer usually does not cause pain. In fact, when breast cancer ﬁrst
develops, there may be no symptoms at all. If you have any concerns or ﬁnd
even a small change, call your doctor. Some symptoms that may indicate breast
cancer include, but are not limited to:

l Nipple discharge or tenderness
l Lumps in breast/underarm area
I Visual change, including:
- Size of the breast, including swelling
— Inverted nipple (which looks as though it has caved in)

— Pitting (the skin looks like the skin of an orange)
or scaling of the breast skin

Your breast health

Early detection can help save lives. There is a 97% ﬁve-year survival rate when
breast cancer is caught before it spreads to other parts of the body. Follow the
recommended guidelines to aid in early detection of breast cancer. If there is a

history of breast cancer in your family, consult your doctor and start earlier than
noted below.

Who is at risk for breast cancer recurrence?

Patients at a higher risk of recurrence include those whose cancers had
previously spread to the lymph nodes and whose tumor was larger in size.
Estrogen receptor status, menopausal status and family history are also factors *

Approximately one—third of women with estrogen-receptor positive early breast
cancer experience a recurrence, and over half of those recurrences occur more
than ﬁve years after surgery **

Reduclng the risk of recurrence

Guidelines from the American Society of Clinical Oncology (ASCO), a leading
physician's association, recommend that post menopausal women diagnosed
with early breast cancer, use an aromatase inhibitor as treatment after 2-5 years
of tamoxifen therapy to reduce the risk of tumor recurrence ‘**

Whether surgery was recently completed or undertaken several years ago.
women concerned about ongoing risk or relapse and options that may be
available should talk to their doctor

'Saphner T Annual Hazard Rates of Recurrence for Breast Cancer after Primay Therapy. J Clin.Oncol.1996.14.2738—2746.
° Introduction and methods sections reproduced from: Eany Breast Cancer Trialists' Collaborative Group' Treatment of Early
Breast Cancer Volume 1. Worldmde Evrdence 1985 1990' Oxford Un’wersity CTSU. Iltlpl/I'MNWW ctsu. ox. ac. uk. Accessed:
August 21. 2004.
“ Goes PE. Ingle JN. Martino S. ct al Updatec Analyse of the NClC CTG MAJ 7 randomlzed placebo (P) controlled trial of

letrozole (L) after ﬁve years of tanioxilen In posmiemmusal women with early stage breast cancer [abstract]. P1700 Am Soc
Clm Oncol. 2004:2387 [Abstract 847].

"‘ther E. American Society of Clinical Oncology Technology Assessment on the U30 oi Aromazase Inhibitors As Antwant
Therapy tor Postmenopausal Women With Hormone Receptor-Possum: Breast Cancer: Status Ropon 2004. J. Clin. Oncol.
‘ 2004' 23. 1-11

A V O N
3 sou «mm o~ BREAST HEALTH nesounce cums

 

 

 

 

Source: Avon Foundation, Puerto Rico Ofﬁce, 2007

192

According to Margarita Solice,

Young people are very excited about the opportunity to have a doctor speaking
with them, without the white coat (laughs) and just like jeans and everything, and
just the youngest doctors are sent to these, so that the age gap is less and they are
more able to tell you about everything, I mean when you go there, you actually do
clinical examinations in the classes or the young women telling you, asking you
about contraceptive pills and everything. But its very nice and I think we, you can
change something in the culture and the awareness, and even the fear of speaking
about disease and cancer and giving them the message that you don’t really have
to die of cancer and that cancer is not, every time a death sentence. And if you
have understood this then you will not fear to do exams for early detection and
that was what was, fear was the major barrier to early detection in the study that
was done by Komen Italia in 2003 so if you ﬁght the fear you will have the
opportunity that these people will just do what they should do and not just put
their head in the sand. . .and yeah, that is really, I mean I think it’s a nice project
and the ministry does too, because they are funding us (Personal Interview,
Bologna, Italy, October 27, 2008).

Through this educational campaign, Komen Italia is reaching very young women with the
message of awareness and early detection as well as teaching them about breast self-
exams and clinical exams.

In 2007 Avon Malaysia held a charity hi-tea event, Saving Lives T hru ’ Early
Detection, as part of the WAWBC events. The funds raised by the event are being used
“to ﬁnance about 25-odd breast health educational workshops at the grassroots
communities in Malaysia” (Avon 2007). According to Avon Malaysia,

These hands-on workshops will be conducted by Breast Cancer Welfare

Association (BCWA) volunteers to train women in the local communities on the

importance of saving lives through early detection of breast cancer and the

techniques of breast-self examinations. Those trained in these workshops will
then be empowered to share the knowledge and skills with the members of their
respective communities, particularly in smaller towns and rural villages (Avon

Foundation 2007).

Through these educational workshops, Avon Malaysia is able to reach a greater number

of women throughout the country, rather than only the self-selected group of women who

attend their events. Again, the educational component consists of raising awareness about

193

the importance of early detection and teaching women how to perform breast self—exams
so that they are able to understand breast health issues and teach other women about what
they have learned.

Through the Global Initiative for Breast Cancer, SGKC advocates are working in
Brazil, Costa Rica, Jordan, Mexico, Panama, Romania, Saudi Arabia, Ukraine, and the
United Arab Emirates to adapt Komen’s advocacy model to these countries’ political and
cultural realities. As part of this initiative, SGKC advocates

work with government entities and non-governmental organizations (NGOS) to

educate girls and women about breast health and breast cancer through

community-based training workshops. The workshops will include grassroots
health educators, NGO workers, nurses, students and local community leaders. As

a result, a network of dedicated, trained advocates will be put in place, armed with

the tools they need to improve breast cancer outcomes (SGKC 2008).

Through this initiative, biomedical breast cancer advocates are training new biomedical
breast cancer advocates, who will be equipped with information regarding early
detection, breast self-exams, clinical exams, and mammography in order to develop their
own awareness campaigns in their respective countries.

In addition to speciﬁc campaigns and programs designed to disseminate breast
cancer information, SGKC and Avon Foundation events often also consist of an
educational component. Race for the Cure events, for example, always entail educational
presentations either the day prior to or the day of the event. The educational component
of the event is often referred to as the Prevention Village, which consists of a tent, or a
number of tents, where lectures are given regarding breast self-exams, clinical exams,
mammograms and the importance of early detection. For example, the Villaggio della

Prevenzione (Prevention Village), held the day before the Race for the Cure in Bologna,

Italy, consisted of a tent with folding chairs facing a large white screen for a PowerPoint

I94

 

 

presentation. A young, female breast surgeon working with SGKC gave a presentation
about breast cancer four times throughout the day, each time for an audience of about ﬁve
to ﬁfteen women. The doctor discussed the importance of early detection of breast
cancer. She explained how to do breast self-exams, while pictures on the screen
demonstrated what she was saying. Mammograms and clinical breast exams were also
discussed with regard to the appropriate age to start having these exams and how often
one should have them.

Avon events also frequently contain an educational component for the
dissemination of medical information. In 2006, for example, in describing the WAWBC
events in Thailand, Avon Thailand reported that “There were a number of activities at the
event including, educational exhibition booths, like a booth demonstrating how breast
cancer testing is performed” (Avon Foundation 2008). In Japan in 2006, a series of breast
cancer lectures designed to raise awareness and disseminate information about breast
cancer risk, self-exams, clinical exams, and mammograms “took place across the country
throughout the month of October” (Avon Foundation 2007).

Finally, in addition to educational materials, lectures and workshops, biomedical
breast cancer advocacy organizations also disseminate medical information through
newspaper stories and television advertisements. In Italy, for example, SGKC urged
Metro, a free daily newspaper distributed through the Italian public transit system, to run
a brief “pink ribbon” article every day during October, Breast Cancer Awareness Month.
The content of these articles varied from announcing and reporting on RFTC events,
explaining how to do a breast self-exam, interviewing breast cancer survivors, and

presenting the latest genetic, detection, and treatment breast cancer-related news. In

195

Puerto Rico, SGKC advertised RFTC events and encouraged the publication of breast
cancer-related health information during the month of October in El Nuevo Dia and EI
Vocero de Puerto Rico, the two most widely-read daily newspapers in Puerto Rico. In
Figure 7.5, the cover page of a special section dedicated to breast cancer in El Vocero is
pictured. The text reads “Educacion: Principal arma contra el cancer de mama,” which
translates to, “Education: the main weapon against breast cancer.” The special section
consisted of articles about heredity and breast cancer, Puerto Rican breast cancer

statistics, how to “prevent” breast cancer through monthly self-exams, annual clinical

exams 311d mammograms.

 

Figure 7.5. Cover Page of a S oecial Section dedicated to Breast Cancer
«its "-

Source: El Vocero de Puerto Rico, Monday, October 6, 2008

Globally expanding biomedical breast cancer advocacy organizations, therefore,
are signiﬁcant sources of breast cancer-related health information, disseminating medical

information via their educational materials, lectures, workshops and media efforts. Given

196

that direct-to-consumer pharmaceutical advertising is illegal in all but a few countries,
most people are not exposed to medical information directly from pharmaceutical
companies. Additionally, because biomedical breast cancer advocacy organizations are
expanding to many countries where breast cancer is not a health priority, public breast
cancer-related health messages were often very limited or non-existent prior to the arrival
of these organizations (WHO 2008). Given the dearth of breast cancer-related health
information globally, biomedical breast cancer advocacy organizations’ dissemination of

medical information becomes even more signiﬁcant.

SURVEILLANCE MEDICINE: EARLY DETECTION AS PREVENTION
According to Klawiter (2008, 87), prior to the 19708 in the US, “early detection” meant

the “absence of delay in consulting a physician if ‘danger signals’ were observed by a
symptomatic woman.” The doctor would refer the woman to an appropriate specialist for
rapid diagnosis and, if necessary, treatment. During the 19708, the previous regime of
medicalization began its transformation into biomedicalization, altering discourse and
practice around “early detection” (Klawiter 2008). The medical gaze, once reserved for
symptomatic patients, refocused on asymptomatic populations and medical professionals
reconﬁgured asymptomatic women “as permanent subjects of the disease regime”
(Klawiter 2008, 87). While doctors utilized mammography, an x-ray technology that uses
ionizing radiation to create images of the breast’s interior, to diagnose breast cancer in
the early 19003, it was not until the mid-19708, that mammography began being used as a
screening technology. Klawiter (2008, 95) describes this as a shift in the discourse and
practice of early detection from “Do Not Delay” to “Go in Search.” It was in the 19803 in

the US that breast self-examination, clinical breast exams, and screening mammograms

197

became the “new trilogy” of doctor-recommended breast cancer discourse and practice
(Klawiter 2008, 95). This shift in early detection discourse and practice ushered in
“surveillance medicine,” the “creation of potentially diseased persons through risk
analyses of individuals, communities, and populations” (Clarke et al. 2005, 22).

The trilogy of self-examination, clinical breast exams and screening
mammograms is now being promoted globally by biomedical breast cancer advocacy
organizations. As discussed in the previous two sections, SGKC and the Avon
Foundation in their global expansion endeavors are spreading awareness and providing
medical information about the importance of breast self-exams, clinical exams and
mammography. In addition to their awareness and educational messages, SGKC and the
Avon Foundation also provide free breast cancer screening during their various events,
programs and campaigns that are targeted to medically-underserved populations.

SGKC and the Avon Foundation’s international events almost always involve
opportunities for women to receive free breast cancer-related screening. Breast cancer
specialists working with SGKC or invited by the Avon Foundation attend the events to
provide medical exams. Some events offer clinical exams, which involve a doctor taking
a woman’s medical history and examining her breasts visually and physically. In addition
to clinical exams, at many events mammograms and/or ultrasounds are also offered. This
is usually possible through the use of a mobile mammography unit, as shown in Figure
7.6. These units are often donated by a pharmaceutical company, medical technology
company, and/or a hospital in collaboration with SGKC or the Avon Foundation. As

demonstrated by the text on side of the mobile mammography unit in Figure 7.6, the unit

198

 

 

 

at the Race for the Cure in Bologna, Italy was funded by Komen Italia, Gemmeli
Hospital, and Johnson & Johnson Medical.

Emphasis is often placed on the fact that the provision of ﬁee screening at events
is especially intended for underserved populations of women. For example, in 2007 Avon
China launched a Kiss Goodbye to Breast Cancer program, “For Our Sisters’ Health and
Happiness,” in 30 cities across China (Avon 2007). According to Avon Foundation’s
press release about the campaign,

In each city, 100 women, being jobless or with very low income, enjoyed a set of
ﬁee services sponsored by Avon and the local medicine industry. The services
included lectures taken by gynecologists, health consultation and examinations
with the most up-to-date technologies on breast and cervix. Pamphlets on
preventing breast and cervix were also spread in those cities (Avon 2007).

Similarly, in Italy, Margarita Solice, a breast surgeon working with Komen Italia,
discussed medical screening at Race for the Cure events by stating,

We would like to target the kinds of people that cannot use the regular health
system and also to women with the regular health system but are maybe too
young to be in a screening program or that will not do it for cultural reasons so
homeless people or we have these nomads that came from Russia, that now live in
Italy. They have the national health system but they will not go there so we
address the organizations that go to their village and maybe they will be able to
take one or two or three women to us and just to reach people that normally are
not reached by every other program and it seems to me that it is difﬁcult to get
these people involved, it’s really difﬁcult, that maybe they tell you ok we will
come and then they don’t show up. We usually also give the chance to other
people just showing around they come and they will also be able to do this and in
Rome since we have the opportunity to perform a lot of exams and everything we
will also give people the opportunity just to phone because there are a lot of
waiting lists in Italy so if they have a problem, they just phone to Komen Italia
and we have a some, a number of exams for them if they need an appointment.
But we would like to target the people that usually would not do a mammogram
under normal conditions for economic or sociocultural problems.

199

 

 

Figure 7.6. Mobile Mammography Unit at Race for the Cure in Bologna, Italy

   

 

 

Source: Personal Photo, Race for the Cure, Bologna, Italy, October 28, 2008

As demonstrated by Margarita Solice’s comments, medically underserved women, or
women who fall outside of the national health program, are sought by Komen Italia to
receive screening at their events.3 ' Despite recruiting these women for free screening,
very few women, less than 40 women at each race that I attended in Bologna, utilized the
free screening. Again, as Margarita Solice’s statement suggests, given that free screening
is available, women are held accountable for taking charge of their own breast health and
should show up to take advantage of the opportunity.

In 2008 Komen Puerto Rico, in partnership with Doral Bank, commenced Ruta
Pink: El camino hacia deteccion temprano del cancer de seno (Pink Route: The Road to
Early Breast Cancer Detection). According to Doral Bank, this community program,

sponsored by Komen Puerto Rico, Doral Bank, Supermarcados Grande, Ford,

 

3‘ Given the national healthcare coverage in Italy, if any woman who has a free screening, but lacks health
insurance, ﬁnds out that she has breast cancer, she will referred to a government hospital for treatment and
her care will be covered by the government.

200

GlaxoSmithKline Oncology, T elemundo, and Senos de Puerto Rico, is “an effort to
promote goodwill throughout the communities that we serve” {Doral Bank \, 2009

#162}.

 

Figure 7.7. Flyer for Ruta Pink in Puerto Rico

  

.....

La Ruta Pink esté Ilevando

bienestar a nuestra comunidad.
Acompéﬁanos en este recorrido por toda la lsIa
donde recibirés:

0 Mamograﬁas gratis a mujeres mayores
de 35 aﬁos sin plan médico '

0 Mamografias sin deducible para mujeres
con plan privado o Reforma

O Referido médico para hacerte Ia prueba

0 Charlas y materiales educativos

Visitanos en una de las 1 1 paradas entre junio
y noviembre por las sucursales de Doral.

La deteccién temprana es la ruta a seguir.
Lo hacemos por tu salud. Lo hacemos por ti.

787.625.5830

www.rutapink.corn

F! Fl susan c. J
,. '_ ‘ - sin-ma, .' .7
@QEJE «Lust Konren a.
. ,. .. ’. _ ”n" CUf c
. ~. . - r. .. .- . . @ pun/:1 o Rico
Mamografias realizadas a través de Servicios Preventives del Caribe. Doral Financial, sue
subsidiaries y afiliadas no son response los do cualquier dnﬁo ﬁslco o emocionel
ocasionado o que pueda ocasionar esra prueba. Consult. con su médico sobre el proceso
mamogra ia.

: s" \3
@Gsmsmmm. (9;. «my @211» .
On<ology . — r'

 

 

 

Source: Komen Puerto Rico, September 12, 2007

201

As described in Spanish in Figure 7.7, the program consists of a mobile mammography
unit that stops in 12 communities around the island of Puerto Rico providing free
mammograms to women 35 and older without health insurance, mammograms with no
deductible for women with private health insurance or “Reforma”, mammography
referrals so that women can schedule a mammogram at their convenience, and
educational lectures and reading materials related to breast cancer.32 Since its inception in
2008, Ruta Pink has provided free mammograms for 1,698 women in Puerto Rico (Doral
Bank 2009). In Italy if a woman is diagnosed with breast cancer based on the results of
her free screening, she would be referred to a government hospital and any necessary
treatment would be covered by the government. In Puerto Rico, however, this is not the
case. If a woman ﬁnds out that she has breast cancer, but is uninsured, she will have to
ﬁnd a way to pay for any necessary treatment. In this regard, by providing free screening
for underserved women in all the countries to which they expand regardless of the
healthcare system, SGKC and the Avon Foundation are promoting surveillance medicine
and women’s individual responsibility to submit to screening, while neglecting broader
issues of healthcare coverage and access to medical treatment, which are crucial if early

detection is to “save lives.”

Survivorship as the Reward for Personal Vigilance
In addition to providing free clinical exams and mammograms at many of their events

and through various programs, SGKC and the Avon Foundation both uphold survivors as

evidence that medical surveillance saves lives by leading to early detection. Survivors are

 

32 “Reforma” refers to the government-run healthcare program, Reforma de Salud de Puerto Rico (Puerto
Rico Health Reform). This program provides medical and healthcare services to indigent and impoverished
citizens of Puerto Rico through the contracting of private health insurance companies, as opposed to
government-owned hospitals (Puerto Rican Department of Health 2005).

202

living proof of the effectiveness of routine medical surveillance. Survivors, therefore, are
praised for their personal vigilance and submission to medical surveillance that led to the
detection (implicitly early detection) of their cancer. At the SGKC Race for the Cure
events in Bologna, Italy in 2007 and 2008, for example, survivors were singled out from
other participants, which is typical of all RFTC events. According to Cecelia Dilleta, a
Komen Italia RFTC organizer, Komen Italia recruits survivors to attend the event and
sets a numerical goal of how many survivors they want to have each year (Personal
Interview, Rome, Italy, October 18, 2007). Francisco Bacci elaborated, stating that
We had committed to having 2,000 participants in this ﬁrst race and hopefully a
sizable number of breast cancer survivors. Actually we had almost 6,000
participants in the ﬁrst year and about 150 breast cancer survivors. And then
from there on it’s just grown, and grown, and grown every year. In 2007 we held
our 8th race in Rome and we had 35,000 participants, 2,000 survivors coming
from all over Italy (Personal Interview, Rome, Italy, October 16, 2007)
The survivors are an important part of these events, as they serve as proof that
undergoing routine medical surveillance saves lives. At the RFTC in Bologna in 2007
and 2008, medical professionals from local hospitals and medical centers, as well as
medical professionals who serve on the board of Komen Italia, spoke on stage after the
race about the importance of early detection and how early detection saves lives. The
breast cancer survivors, wearing pink shirts and baseball caps provided by Neutrogena,
the official sponsor of survivors at the Race in Bologna, were seated in a special section
directly in front of the stage, while other supporters and participants surrounded them in a
standing section. In speaking about early detection and the importance of getting routine
mammograms and performing self-exams, doctors often gestured toward the survivors

while stating that they are the proof that early detection and subsequent medical

intervention saves lives.

203

    

Source: Personal Photo, Race for the Cure, Bologna, Italy, October 28, 2008

Avon’s Global Connection Ribbon Tour spreads a similar message, celebrating
survivorship as evidence that awareness, early detection, and personal vigilance save
lives. At the GCRT event in Malaysia, for example, the visiting survivor from Japan, who
was diagnosed with breast cancer in 2004, shared her experience, ending her speech by
saying “there is life after breast cancer, but you must have early detection and regular
screening” (Avon Foundation 2007). Early detection, often interchanged with the term
“prevention” at biomedical breast cancer advocacy events, therefore, is presented not as
preventing breast cancer per se, but as preventing death from breast cancer.

Death from breast cancer at these events is portrayed as resulting from a lack of
awareness about breast cancer, which in turn leads to late-stage diagnosis, and
unnecessary, or preventable had it been caught earlier, death from breast cancer. In
addition to the presence of survivors at events, stories of death from breast cancer are
used to emphasize the importance of early detection. For example, at the 2008 Avon
WAWBC event in Estonia, an Avon representative recounted the story of losing her
mother to breast cancer, stating, “I can not stress enough, the importance of early

detection to save lives” (Avon Foundation 2008).

204

By providing medical screening through events and campaigns and praising
survivors as proof that personal vigilance with regard to regular breast cancer screening
saves lives through early detection, biomedical breast cancer advocacy organizations are
globally promoting a form of advocacy that upholds medical surveillance and individual
responsibility as paramount in confronting breast cancer. As argued by King (2006, 104),

While breast cancer survivors are celebrated for their courage and strength within

this model, their success at survivorship is seen to depend on their submission to

mainstream scientiﬁc knowledge and reliance on doctors and scientists to protect
them from death. They—and the public at large—are told to obtain regular
screenings, demand insurance coverage for mammograms, explore a range of
treatment options, and talk to other survivors, but they are discouraged from

questioning the underlying structures and guiding assumptions of the cancer-
industrial complex.

CREATING AT-RISK IDENTITIES

Globalizing processes of biomedicalization encompass the shift toward “surveillance
medicine,” which dissolves previous categories of “healthy” and “ill” persons in favor of
new categories of “at-risk-individuals, communities, and populations, using strategies of
pathologization and vigilance” (Clarke et al. 2005, 22). According to Clarke and Oleson
(1999, 14), “surveillance medicine is creating a new culture of risk and new burdens of
health care consumption that particularly implicate women.” As the slogan on the back of
the 2007 Race for the Cure shirts in Lansing, MI stated “The greatest risk factors for
getting breast cancer are being a woman and getting older,” thereby constructing all
women as being on a “risk continuum,” in which they are always at risk due to their
gender, and at increasing levels of risk as they age and based on any other risk factors
that they may have (Klawiter 2002).

Being “at risk” is now being transformed into “requiring biomedical

prevention/intervention” (Clarke et al. 2005, 22). Processes of biomedicalization also

205

transform the concepts of health, risk and surveillance, bringing discourses of risk to the
forefront of medical attention. Whereas processes of medicalization redeﬁned social
problems as medical illnesses, disabilities and/or diseases, processes of biomedicalization
have redeﬁned health so that the lack of symptoms does not necessarily indicate the lack
of illness or potential illness. Therefore, health must be maintained through biomedical
surveillance and risk assessment (Clarke et al. 2005, 446). Individuals who may
otherwise appear and feel healthy are deﬁned as “at risk” based on family history,
personal behaviors, and/or results from genetic testing. Risk is then managed through
“processes of surveillance, screening, and routine measurements of health indicators”
(Clarke et a1. 2005, 448). Through biomedical screening, breast cancer was “reinvented
as an invisible risk and symptom-less disease that required continuous bodily vigilance
and surveillance” (Klawiter 2008, 38). According to Klawiter (2008, 38),

Breast self-exam, clinical exam, and mammographic screening were heavily

promoted and discursively constructed as the moral duty of every woman. As this

occurred, the temporary sick role for symptomatic women was replaced by a

permanent “risk role” for all women. Biomedicalization thus reconstituted

healthy, asymptomatic women as risky subjects and transformed the disease from
an either-or condition to a breast cancer continuum.

Over the past twenty-ﬁve years, biomedical breast cancer advocates have stressed
the permanent “risk role” for women, emphasizing that all women are at risk for breast
cancer, even though some women may be at greater risk than others. The message of the
1 in 8 lifetime risk of breast cancer is ubiquitous in the US, which is largely due to the
efforts of biomedical breast cancer advocacy organizations. It is pertinent to note that
most women in the US overestimate their risk of breast cancer and underestimate their

risk of heart disease, diabetes, and other more prevalent diseases (Phillips et al. 1999). In

order to responsibly respond to the 1 in 8 breast cancer risk statistic, women in the US

206

 

 

have learned the appropriate behaviors, largely due to biomedical breast cancer
campaigns. Not only do women know that they are supposed to abide by the trilogy of
self-exams, clinical exams, and mammograms, but they are also encouraged by reminders
from SGKC and their corporate sponsors to remind other women to comply (N CI 2009).
These “risk messages” are now being promoted globally by SGKC and the Avon
Foundation, facilitating the creation of new “at risk” identities among women who, in
many cases depending on their geographic location, may not need to be concerned about
their breast cancer risk, or may have other health-related issues with which to be more
concerned.

Just as in the US, SGKC and the Avon Foundation are now disseminating risk
information regarding breast cancer in other countries. Figure 7.9 is an excerpt from a
Komen Puerto Rico pamphlet about breast cancer. The page on the left in Figure 7.9 is
entitled Conceptos Basicas Sabre la Salud del Sena, which translates to “Basic Concepts
About Breast Health.” The basic concepts include information regarding breast cancer
statistics, breast cancer risk, and SGKC’s recommendations for dealing with risk. The
ﬁrst section entitled C onozca la realidad sobre el cancer de seno (“Know the reality
about breast cancer”) states that breast cancer is the main cause of death among Hispanic
women, breast cancer is the most common form of cancer among Hispanic women, and
when breast cancer is detected early, at a localized stage, chances of survival are much
better than when it is detected at an advanced stage.33 This information is followed by the
section entitled Corra el riesgo de tener cancer de seno? (“Do I run the risk of having
breast cancer?”), which states that all women run the risk of having breast cancer, that the

greatest risk factor is being a woman and that risk increases with age, that many women

 

33 Breast cancer is not the main cause of death among Hispanic women, heart disease is (CDC 2004)

207

who get breast cancer don’t have any additional risk factors and that even though it is
more common for women to get breast cancer aﬁer the age of 40, younger women can
also get breast cancer. Finally, it mentions that while rare, men can also get breast cancer.
In the next section SGKC recommends dealing with the risk of breast cancer that comes
with being a woman by being vigilant when it comes to self-exams, clinical exams and
mammograms in order to catch breast cancer at its earliest stage, thereby increasing the
likelihood of survival. The page on the right consists of questions and answers regarding
the implications of family history, alcohol use, contraceptive pills, exercise, and
ﬁbrocystic breasts for breast cancer risk. Notably, the risk factors mentioned are all
individual risk factors, which in the case of alcohol use, birth control pill use, and
exercise are in the woman’s control. While family history and ﬁbrocystic breasts are not
within a woman’s control directly, the advice given places responsibility on the woman to
know her family history, discuss this history with her doctor, and seek additional medical
screening if recommended. For ﬁbrocystic breasts, which do not increase breast cancer
risk but may make detecting a lump through self-exams more difficult, the advice given
places the responsibility on the woman to know her breasts well, so that if a change
occurs, she will be able to detect it. The provided information, therefore, deﬁnes all
women as “at-risk” for breast cancer and as personally responsible for mitigating this risk
by adhering to the trilogy of self-exams, clinical exams, and mammography, without

reference to access to care or insurance coverage.

208

 

Figure 7.9. Breast Cancer Risk Information

A 1

Conceptos Bésicos
Sobre la Salud del Seno

  
    

Conozca la realidad 0
sobre el cancer de seno. susan c.

0 El cancer dc seno es la causa principal dc
muerte entre las mujeres hispanas.

0 El cancer dc seno es cl ca'ncer més comt’m entre
las mujeres hispanas.

' Cuando el cancer de seno se detecta temprano y
sc limira al area del seno, las oportunidadcs de
sobrevivir son mucho mayores.

 

éCorro el riesgo de tener

céncer de seno? Susan G. Komen for the Cure

recomienda lo siguiente:

° Todas las mujeres corren cl riesgo de tener
cancer dc seno. 1. I-Ia'gasc una mamografia (examen del seno con

rayos X) cada aﬁo dcsdc los 40 aﬁos.

0 Si usted riene menos de 40 aﬁos, y alguien en
su familia ha tenido cancer de seno, o esta
preocupada por la salud de sus senos, hable
con su doctor.

' El ser muier es el factor de riesgo numero
uno para el cancer de seno. Su riesgo dc tener
cancer de seno aumenta con la edad.

' Muchas mujeres que han tenido cancer de seno

no tienen ningt’m factor adicional dc riesgo. .
2. Hagase un examen ClInICO de los senos por su

| 0 Aunque el cancer dc seno es mas comfm en doctor 0 enfermera por lo menos cada 3 aﬁos
l mujeres mayores de 40 aﬁos, las mujeres més dcsdc los 20 aﬁos de edad, y cada aﬁo después

jévenes también pucdcn desarrollar cancer de los 40 aﬁos.

de seno.

3. Hagase un autoexamen del seno cada mes a
0 Los hombres también pueden tener cancer de partir de los 20 aﬁos de edad_
““0 pcro 55 ”11'0- ES aproximadarnente 100 0 Familiariccsc con sus senos. lnférmele a su
VCCCS més comun en mujeres. doctor 0 cnfermera sabre cualquier carnbio.

 

Para mas informacion llame al: 1-800-462-9273 0 visite www.komen.org

  

  

.m .

 

Source: Komen Puerto Rico, October 16, 2007
Figure 7.10. Excerpt from Avon Foundation’s Resource Guide in Puerto Rico

209

 

 

 

 

WHAT EVERYONE
SHOULD KNOW ABOUT
BREAST CANCER

Important u.s. facts:

I Approximately 214,640 people in the US. will be diagnosed with
Invasive breast cancer this year — including 1 ,720 men.

 

I 40,970 women and 460 men will die from the disease annually.

I One person is diagnosed approximately every 3 minutes. and
one person dies of breast cancer approximately every 14 minutes

I People over the age of 50 account for 77% of breast
cancer cases.

I Breast cancer is the most commonly diagnosed cancer among
Hispanic women and is the leading cause of cancer deaths among
this group.

I Breast cancer ls the most common cancer among African-
American women. but ranks second to lung cancer in cause of
cancer deaths.

I White. non-Hispanic women are more likely to develop breast
cancer but African-American women are more likely to die from it.

 

Your history and habits:

All are at risk of getting breast cancer. Below are some factors that
increase your risk:

I Gender — men can get breast cancer. but they account for only
about 1 % of cases.

I Aging — only about 5% of breast cancer diagnoses are under
age 40 and approximately 18% are in their 405. while more than
three-quarters of new cases are diagnosed after age 50.

I Menstruation and reproductive history — risk is increased
by onset of menstruation before age 12, menopause after 50. ﬁrst
child after 30 or no children.

I Famiiy history of breast cancer increases risk — especially if
close relatives are diagnosed before the age of 50. A ﬁrst degree
relative (mother. sister, daughter) with breast cancer approximately
doubles the risk of breast cancer.

I Diet and weight — being overweight is linked to a higher risk of
breast cancer, especially after menopause.

CC
LL]
C.)
2
q
C.)
.—
3
I:
m
.—
=
0
ca
<1
3
o
z
x
c:
4
=
o
I
(D
I.”
2
c:
>-
a:
E
h
<
I
5"

Sources: American Cancer Society and The National Cancer Institute.

N

 

 

 

Source: Avon Puerto Rico, October 16, 2007
Similarly, Figure 7.10 is an excerpt ﬁ'om Avon Foundation’s Resource Guide,

which is distributed throughout the world with every purchase of an Avon Breast Cancer
Crusade product. This particular resource guide is distributed throughout the Caribbean
in Spanish and English. The information provided is based on US breast cancer statistics

with an emphasis on Hispanic women’s breast cancer risk. Like the SGKC educational

 

210

pamphlet, Avon’s resource guide also stresses the fact that all women are at risk for
breast cancer, while certain women may have an increased risk based on family history of
breast cancer, menstruation and reproductive history, and diet and exercise, placing all

women on a breast cancer risk continuum.

CONCLUSION
In this chapter, I have argued that through the diffusion of their advocacy events,

campaigns and programs, globally expanding biomedical breast cancer advocacy
organizations are furthering processes of biomedicalization on a global scale. By raising
awareness about early detection and disseminating medical information, biomedical
breast cancer organizations are promoting surveillance medicine and creating new at-risk
identities among women across the globe. Biomedical breast cancer advocacy
organizations are playing a signiﬁcant role in establishing a biomedical understanding of
breast cancer outside of the US by engaging in awareness-raising activities and
disseminating medical information about breast cancer.

This chapter demonstrates how advocacy organizations can act as agents of
globalization. While most social movement literature focuses on how advocacy
organizations respond to globalization, biomedical breast cancer advocacy organizations
are an example of how these organizations also contribute to globalization. As shown in
this chapter, biomedical breast cancer advocacy organizations are actively promoting a
particular brand of health advocacy, “awareness advocacy,” which is often unfamiliar to
the countries within which they are expanding. In addition to spreading a speciﬁc type of
health advocacy, SGKC and the Avon Foundation, through their breast cancer events,

campaigns and programs, are also furthering processes of biomedicalization.

211

Culturally transplanting messages of breast cancer awareness, education, and
screening, while not all bad, does have signiﬁcant implications for processes of
biomedicalization, the political economy of health and illness, and individual women. By
creating new “at risk” identities among women globally and advocating for increased
medical screening, biomedical breast cancer advocacy organizations are generating
proﬁts for medical institutions, as well as medical experts, who own screening
technologies. Additionally, in the process of creating “at risk” identities, while promoting
awareness and medical surveillance, SGKC and the Avon Foundation are expanding the
market for breast cancer-related preventative pharmaceuticals and medical screening
equipment, which will be discussed further in Chapter 8. As has occurred in the US,
where breast cancer risk is actually relatively high compared to most of the world, the
cultural transplantation of awareness and risk messages may skew women’s perceptions
of their health risks and affect health priorities in countries where breast cancer may
necessitate such attention. Finally, the focus on individual vigilance with regard to breast
cancer risk and assessment neglects healthcare infrastructures, which may or may not,
depending on the country, have the ability to properly treat breast cancer when it does
occur. Providing access to free screening to medically underserved communities ignores
the broader issue of why they are underserved to begin with and whether or not they will
have access to treatment should they ﬁnd out that they do in fact have breast cancer.
Finally, this form of advocacy is globally promoting an approach to cancer that relies on
the saving graces of medical technology, while ignoring issues of prevention and causes

of breast cancer altogether.

212

Much of the literature on biomedicalization has focused on the role of medical
professionals and the pharmaceutical industry in promoting processes of
biomedicalization in order to monitor “at-risk” individuals, communities, and populations
and increase proﬁts, respectively. By examining the globally proliferating activities of
biomedical breast cancer advocacy organizations in this chapter, I have demonstrated that
biomedical advocacy organizations are also contributing to processes of
biomedicalization and need to be accounted for not only by social movement scholars,
but also by sociologists of health and illness interested in the global expansion of

processes of biomedicalization.

213

CHAPTER 8

THE GLOBAL DIFFUSION OF CAUSE-RELATED MARKETING VIA
BIOMEDICAL BREAST CANCER ADVOCACY ORGANIZATIONS

While I focused on biomedical breast cancer advocacy organizations’ promotion of
individual responsibility to “take charge” of one’s health by submitting to surveillance
medicine in Chapter 7, in this chapter I address the organizations’ promotion of
individual and corporate responsibility to raise funds in support of biomedical breast
cancer research and treatment. Focusing on cause-related marketing, the predominant
form of fundraising that SGKC and the Avon Foundation are expanding internationally, I
argue that biomedical breast cancer advocacy organizations are globally expanding a
hybrid form of “corporate advocacy” that relies on the participation of “consumer
advocates.” While this form of advocacy, having been promoted by SGKC and the Avon
Foundation for over 20 years, has become ubiquitous in the US as an increasing number
of corporations adopt cause-related marketing strategies, it is often being introduced into
other countries for the ﬁrst time, or at least at an early stage in its development.

Further, I argue that the global promotion of this form of corporate advocacy is
signiﬁcant within the global political economy of health and illness because it champions
corporatized and individualized solutions to health-related problems. The global
expansion of cause-related marketing and corporate-advocate partnerships as new forms
of health advocacy that create corporate-advocate and consumer-advocate identities is
signiﬁcant in that it detracts from health advocacy aimed at reforming healthcare
systems, problematizing unequal access to care, and questioning the causes of diseases.
Instead, corporate advocacy, via cause-related marketing campaigns, raises money for a

speciﬁc disease, based on the participation of consumer-advocates, who through their

214

engagement in corporate-sponsored events (i.e., by paying a registration fee) and their
purchase of designated products fund these endeavors.

While SGKC and the Avon Foundation are not in the business of cutting public
expenditures on healthcare, their approach to breast cancer advocacy complements
neoliberal agendas by proposing corporate (advocacy) and individual (consumer)
solutions to breast cancer. As deﬁned by King (2006, xxvi), neoliberalism is “a
philosophy and a set of economic and political policies aimed at cutting expenditures on
public goods such as education, healthcare, and income assistance in order to enhance
corporate proﬁt rates.” The exclusively biomedical approach to breast cancer advocacy
being promoted by SGKC and the Avon Foundation potentially enhances corporate proﬁt
rates. In addition to beneﬁts that accrue to companies, including the Avon Company, the
ﬁnal section of this chapter addresses the allocation of funds raised through fundraising
events and cause-related marketing internationally demonstrating that medical
researchers, cancer research centers, pharmaceutical and medical technology companies

beneﬁt.

A BRIEF HISTORY OF CAUSE-RELATED MARKETING

Cause-related marketing emerged in the mid-19805 as a strategic marketing tool for
differentiating a brand and adding value to it (Pringle 1999). According to Carol Cone,
founder and CEO of Cone Communications, “Companies and brands associate
themselves with a cause as a means to build the reputation of a brand, increase proﬁt,
develop employee loyalty to the company, and add to their reputation as good corporate
citizens” (Carol Cone as quoted in King 2006, 9). According to King (2006, 9), since the

19903, cause-related marketing has

215

 

evolved from what were mostly relatively short—term commitments of one- or

two-month promotions with a charitable organization at the end of which the

corporation donated a portion of its proﬁts—to major long-term commitments to

an issue through an alliance that links the company or brand name with the issue

in the consumer’s mind.
Given the state of competition among companies, in addition to trying to gain an edge by
cutting prices, increasing advertising, and improving technology, a growing number of
companies are utilizing long-term cause-related marketing strategies to “attract the
attention and loyalty of the consumer, who is understood to be increasingly adept at
reading marketing messages and dissecting the meaning and symbolism of any particular
commercial or advertisement” (Pringle 1999, 12).

Cause-related marketing campaigns have been proliferating in the US since the
early 19905. In addition to breast cancer cause-related marketing campaigns, there are
similar campaigns for diabetes, heart disease in women, multiple sclerosis, and ovarian
cancer, just to name a few. While cause-related marketing is becoming increasingly
common in the US, forcing brands to compete more aggressively for brand recognition
and customer loyalty, cause-related marketing campaigns are in the early stages of
expanding internationally (King 2006). According to King (2006, 10), “in so-called
developing markets the priority for marketers and brands is to achieve rapid gains in
consumer ‘penetration’ and market share.” Therefore, while companies promoting cause-
related marketing campaigns in the US may only hope to secure customer loyalty, in
developing markets “the battle is all about acquiring new customers before the
competition does” (Pringle 1999, 14).

Although cause-related marketing campaigns around a variety of issues exist in

the US, breast cancer is often singled out as being an ideal cause. Marketing experts have

216

“labeled breast cancer ‘a dream cause’ and pointed to the success of corporate campaigns
against the disease as a way to encourage other companies to pursue cause-related
marketing” (King 2006, 14). According to King (2006, 111),

Breast cancer became a philanthropic cause par excellence not simply because of
effective political organizing at the grassroots level, but because of an informal
alliance of large corporations (particularly pharmaceutical companies,
mammography equipment manufacturers, and cosmetics producers), major cancer
charities, the state, and the media that emerged at around the same time and was
able to capitalize on growing public interest in the disease.

The “popularity” of breast cancer among corporations has produced “intense competition
as corporations struggle, in the words of Avon’s Joanne Mazurki, “to gain ownership

over the issue” (King 2006, 14).

Both SGKC and the Avon Foundation are noted for being particularly adept at
marketing breast cancer. Nancy Brinker is oﬁen credited with pioneering cause-related
marketing, as demonstrated in the following excerpt from TIME Magazine’s article on

the “100 Most Inﬂuential People,”

Not only did Ambassador Brinker found the organization that has become
synonymous with breast cancer globally, she brought the disease out of the
shadows of secrecy and shame in large part by launching Komen for the Cure’s
well-known and emulated Susan G. Komen Race for the Cure Series®, the
world’s largest and most successful education and fundraising event for a charity
and the precursor to the booming cause-related marketing movement. Susan G.
Komen for the Cure is known as a pioneer in the cause-related marketing
industry, and thanks to Ambassador Brinker ’s pioneering eﬂorts, the organization
boasts partnerships with more than I 70 companies” (my emphasis, SGKC 2008).

Similarly, as emphasized by Gabriella Lopez at Avon Puerto Rico,

As a tagline of our Company we say we are the company for women because
[breast cancer] is a disease that is affecting mostly women so they [Avon
Foundation] adopt that. And [Avon] was the ﬁrst company I think that start with
this movement of awareness and doing something to increase the awareness of
breast cancer and raising money and everything like that (my emphasis, Personal
Interview, Caguas, Puerto Rico, September 14, 2007).

217

Given the strong histories and successes that SGKC and the Avon Foundation have had
with cause-related marketing in the US, it is not surprising that these two organizations in
particular would lead the way toward cause-related marketing campaigns on an

international scale.

GLOBAL EXPANSION OF CAUSE-RELATED MARKETING

Walking down store-lined streets and browsing grocery stores, coffee shops, drug stores,
department stores and boutiques in Rome and Bologna, Italy and San Juan, Puerto Rico
during September and October of 2007 and 2008 differed drastically from my experience
with the ever-proliferating pink products lining the shelves in a variety of stores in the US
during Breast Cancer Awareness Month (BCAM). During October in the US, without
purposely seeking pink products, I am routinely inundated with cause-related marketing
campaigns promoting the purchase of food, wine, tea, clothing, cosmetics, cars, and
airline tickets, just to name a few, as a form of corporate- and consumer-advocacy, to
beneﬁt biomedical breast cancer research. Based on my research experience in Puerto
Rico and Italy as well as documentary analysis, cause-related marketing is not nearly as
prevalent internationally as it is in the US, although it seems to be gaining ground quickly
particularly in Western European countries, and biomedical breast cancer advocacy
organizations are often at the forefront of cause-related marketing campaigns globally.
SGKC and the Avon Foundation, with very few cultural adaptations, are
expanding their cause-related marketing campaigns internationally. The Avon Company
incorporates cause-related marketing in their product brochures, expanding their cause-

related marketing of breast cancer products to over 50 countries.

218

Fi_ure 8.1. Avon Breast Cancer Crusade Products

Cruzada contra el
cancer del seno

     

‘ we“ seem new is" is

i“... radii? “seanwemmaﬁ’h W Kai
Source. Avon Puerto Rico, October 14,2007

Figure 8.1 is an example of the breast cancer crusade page in Avon brochures. These
products are featured in the brochures during four campaigns throughout the year, and

this is consistent in all countries where Avon sells its products. The products are mostly

219

the same, but are described in the country’s native language. The campaign not only
consists of the selling of the products by Avon representatives via the brochure. The
Avon Foundation also launches a media campaign to promote the breast cancer-related
products. Rather than advertising through the Avon Company, the Avon Foundation is
often able to receive media coverage free of cost or at a reduced cost given the

organization’s non-proﬁt status. As explained by Gabriella Lopez,

 

I...

We also made a media tour that started last week. We start a month early because
the brochure starts in October, but these [What’s New] brochures start one month
early. We have representatives with already this brochure in their hands so we
wanted to start the campaign really early in the media so they can deliver the
products, or we have customers that asked for, I saw the product on the TV and do i
you have it, yes I have it. Not to wait to October to have that. So that’s the same

thing with this commercial, we are going to be on air the last two weeks of

September and the ﬁrst two weeks of October, because these brochures are out.

So we were on the radio and in morning news and we also started receiving some

coverage in the media in beauty magazines, they are going to be showing some

images of the products in October (Personal Interview, Caguas, Puerto Rico,

September 14, 2007).

The Avon Breast Cancer Crusade, therefore, draws media attention for the Avon
Company, emphasizing the Company’s commitment to women based on its “corporate
advocacy.” While companies, including Avon, engaging in cause-related marketing
campaigns hope to bolster their proﬁt via increased brand recognition and loyalty, the
funds garnered through the sale of breast cancer products usually beneﬁt a breast cancer
NGO, allowing consumers to feel good about their purchases.“

In addition to Avon’s cause—related marketing campaigns in Puerto Rico, Komen
Puerto Rico is also expanding cause-related marketing efforts on the island. As shown in
Figure 8.2, Komen Puerto Rico and Mazola developed a corporate-advocate partnership

through SGKC’s Bake for the Cure campaign. The advertisement, appearing during

 

 

3’ Speciﬁcs about the allocation of funds will be discussed in a later section of this chapter.

220

Breast Cancer Awareness Month in El Nueva Dia presents Komen Puerto Rico and
Mazola as “unit ” in the ﬁght against breast cancer, an example of corporate advocacy.

Advertisement in Puerto Rico“

lEQDEMOS!

Fi - ure 8.2. Mazola Cause-Related Marketin_

 

 

- ‘3‘

,1 "o

"NE—TE A T‘a’lAI’DLA EN LA LUCI‘JA CONT HA EL CANCER PEL SEF‘JQ

maﬁoda1m$250.000calammdc|6nme. ,
m tor the Canal! ' ‘ ‘ ‘ 4“ ' , (‘m
' Mbukmm m 91%

 

 

Source: El Nuevo Dia, San Juan, Puerto Rico, Wednesday, October 1, 2008

‘The text in the advertisement reads, Podemos! Unete a Mazola en la Lucha Contra el Cancer del Seno.
Este aho donaremos $250,000 a la fundacion Susan G. Komen for the Cure. iuntos hacemos la diferencia.
Bake for the Cure beneﬁts Susan G. Komen for the Cure. www.bakeforthecure.com. This translates to We
Can! Unite with Mazola in the ﬁght against breast cancer. This year we are donating $250,000 to the
foundation Susan G. Komen for the Cure. Together we can make the difference.

In Italy, cause-related marketing is beginning to take off as well, primarily due to
the efforts of Komen Italia. Rather than reinventing the wheel, Komen Italia began

introducing breast cancer cause-related marketing campaigns in Italy in partnership with

221

multinational corporations that were already engaging in cause-related marketing
campaigns with SGKC in the US. According to Rosa Valentino,

We started with a project with KitchenAid as in the US, with a big blender, it’s

one of these multi-function blenders for the kitchen and I think it costs 299 euro,

and for each blender sold, we get 99 euros (Personal Interview, Rome, Italy,

October 15, 2007).

In Italy, breast cancer NGOS not engaging in cause-related marketing campaigns
often have trouble staying aﬂoat, while Komen Italia, since its inception in 2000, has
taken off, becoming ﬁnancially stable and even expanding beyond Rome to Bologna and
Bari in 2007. As Celia Barolo, a member of Europa Danna in Italy stated,

It is very, very difﬁcult right now to have enough money to be present because in

Italy, in Europe, but mainly in Italy, we don’t have a public, we don’t have an

individual, or citizen feeling to give to the association. . .. This is different from

America. In America it is normal that you send money to somebody, you must

trust of course, but it’s normal for you. In Italy, no. It’s very very difﬁcult. You

can collect money if you organize a big event, so the Komen race is an example,
but at the beginning it was very, very difﬁcult, but now it is the seventh or eighth
edition, by now its becoming different. But it took time, and time, and time. So
it’s difﬁcult for a small organization to have enough money to be present where

you must be present (Personal Interview, Rome, Italy, October 16, 2007).

As this statement demonstrates, SGKC’s forms of advocacy were not familiar to many
Italians at ﬁrst. Multiple people with whom I spoke in Italy explained to me that the non-
proﬁt sector, and the notion of donating money to an organization, like a breast cancer
non-proﬁt, is foreign to Italians, and only recently gaining legitimacy. Celia Barolo said
this is because in Italy, unlike in the US, Italians can rely on, or at least historically have
been able to rely on, their government for basic services like healthcare and education.
Therefore, the concept of donating money to a non-proﬁt to help with these types of

needs seemed unnecessary. Nevertheless, given that SGKC has extensive ﬁnancial

resources, rather than altering its form of corporate advocacy to culturally “ﬁt” in Italy, it

222

held Race for the Cure fundraising events annually and promoted cause-related
marketing campaigns, and over time, and a relatively short amount of time at that, they
became successful in Italy, normalizing a new form of corporate advocacy reliant on the

participation of consumer advocates.

RESPONSES TO CAUSE-RELATED MARKETING AS A NEW FORM OF
ADVOCACY

Given the introduction and early successes of breast cancer cause-related marketing in
Puerto Rico and Italy, it would seem that other breast cancer organizations might model
cause-related marketing fundraising strategies. My ﬁndings indicate that while
corporations are likely to jump on the cause-related marketing bandwagon, some
governmental and non-governmental organizations have had mixed responses. For
example, Europa Donna, the pan-European breast cancer advocacy organization, has not
chosen to emulate SGKC’s form of fundraising advocacy, despite acknowledging Komen
Italia’s success in promoting this form of advocacy in Italy. According to Celia Barolo,
this is because the organizations are ﬁmdamentally different in their approaches to breast
cancer. As she maintained,

They [Komen Italia and Europa Danna] are two very different kinds of work, of
course the main objective is to make more and more curable breast cancer, but of
course, ending breast cancer is the goal of everyone who works in this ﬁeld, but
how we work is absolutely different because one is an advocacy movement,
Europa Donna is an advocacy movement, for advocacy and lobbying and Komen
is a raising funds movement. And of course the breast cancer problems and issues
are in the program of the Komen but how they reach some result is absolutely
different because we want to reach a result in a way of the thinking of the people
of, of the women. As Europa Donna we want to push the politicians to do
something in favor of women, to increase the diffusion of the public breast cancer
screening program for example. In our country, the screening program, the public
screening program covers 60 percent of the Italian territory, but only for the
women aged 50 to 69 with the biannual mammography because we adopted the
breast cancer screening program project from Northern Europe, from Norway,
from Sweden, and so on (Personal Interview, Rome, Italy, October 16, 2007).

223

Europa Danna, therefore, does not direct its energy toward fundraising for breast cancer,
as Komen Italia does. Rather, members of Europa Donna describe themselves as
“advocates” and “lobbyists” working to reform national healthcare coverage and improve
the national screening program. They thereby distinguish their organization as a true
advocacy organization, different from Komen Italia, which they refer to as a fundraising
movement.

While some breast cancer NGOs may not pursue cause-related marketing, other
organizations are following suit, developing their own corporate-advocate campaigns.
The Lega Italiana per la Lotta contra i T umori (LILT), an Italian anti-cancer
governmental organization run by the Italian Department of Health recently began
engaging in cause-related marketing campaigns. As Rosa Valentino of Komen Italia put
it,

In Italy there’s a big campaign [during Breast Cancer Awareness Month] with the

LILT, Lego Italiana per la Lotta contra i T umori. It is another national

association and they made in October a program with Estee Lauder. I think it is

the same in the US, a pink ribbon campaign (Personal Interview, Rome, Italy,

October 15, 2007).

A store front advertisement from the cause-related marketing partnership between LILT
and Estee Lauder is pictured in Figure 8.3. The main text in the advertisement reads
Manda Rosa: Un Manda Senza Cancro al Sena, which translates to “Pink World: A
World without Breast Cancer.” By including information about the organization next to
the products for sale, which are also pink and have the breast cancer pink ribbon on them,

corporate advocacy is demonstrated. Consumers who purchase this product, then, become

consumer advocates, by utilizing their consumption to ﬁnancially beneﬁt a cause.

224

Fi_ure 8.3. LILT and Estee Lauder Cause-Related Marketin_ Cam .ai in Italy

 

Source: Personal Photo, Rome, Italy, October 2008

SGKC’s and Avon Foundation’s cause-related marketing campaigns are rapidly
expanding internationally, particularly as an increasing number of corporations are
participating in cause-related marketing initiatives. Komen Italia, for example, solicits
new companies each year, increasing the number of corporate sponsors for their events
and breast cancer cause-related marketing campaigns that support their organization. For
example, Rosa Valentino described the organization’s arrangement with a new corporate
sponsor,

We have another new sponsor, Stardust, it’s an Italian [cosmetics] company, and

they’re sponsor of the races, and also with them we make a social marketed

project because every month they choose two of their products and 0.50 euro of
each product sold goes to Komen, for one year. And right now we raised

something like 15,000 euro with these products (Personal Interview, Rome, Italy,
October 15, 2007).

225

While it was relatively rare, in comparison to the US, to encounter cause-related
marketing campaigns in Italy, while in Bologna, I came across Sosushi, an Italian sushi
restaurant that was a sponsor of the Bologna Race for the Cure and also engaged in
cause-related marketing by providing a “menu rosa,” or “pink menu,” as shown in Figure
8.4, donating two euro to Komen Italia from each sale of an item on the menu rosa. As a
relatively new restaurant, launched in multiple locations in Italy in 2006, Sosushi was
having a difﬁcult time introducing Japanese food into the Italian diet (Cecelia Dilletta,
Personal Interview, October 18, 2007). Because of this, the owners of Sosushi were
seeking ways to connect with Italians and bring new customers into the restaurants to at
least try sushi. Partnering with Komen Italia provided Sosushi with an opportunity to
draw women into their restaurant through their cause-related marketing campaign, which
according to the text on Sosushi’s menu demonstrates the restaurant’s commitment to
women through its partnership with Komen Italia, and then emphasizing the health
beneﬁts of sushi, particularly for women concerned with a healthy diet once women are

willing to try it.

226

Fi re 8.4. Sosushi Cause-Marketin Cam .aign in Bologna, Italy*

sosushi test menu rosa
0’ . i

scegliendo
il menu rosa

 

 

bologna Iabi
aiuii a soslenere {a
komen tala on‘us

sosushi doneré 2€
per ogni 'renu rosa
l3 run. .j acculstalc

bologna lab2 con i fondi verra'mo
reallzzat progeltl
per la Iotla comro

'lumcn al seno

 

Ilsa-H )0
183! i 30

 

 

 

sosushi for women

“sosushi e Komen ltalia insieme
per la lotta contro i tumori del seno”

sosushi, da sempre vicino all‘universo lemmlnile, alla sua sensibllit‘a 6 al suo
gusto, ha deciso di scendere III campo a favors della Komen Italia On‘us
(www.komenit ), associazlone operativa in tulle ll mondo, allen’nalasi nel tempo
per la sua grande serieta ed ll suo impegno concrete nella prevenziooe e nella
lolta conlro i tumori al seno, malattia che in Italia colpisoe ogni anno 36.000
donne.

ll team or sosushi con numerose iniziative dl fund raising. come il Menu Rosa

a cone di beneﬁcenza. donera almeno 10.000 euro eniro il 1 settembre 2009
all'associazione.

Inolire Sosushi, soslenendo e sponsorlzzando la “Race for the Cure", maratona
che la Komen llalia organizza ogni anno a Roma, Bari ed ora anche a Bologna
(ll 28 di seltembre ai Giardini Marghema), si impegna, dimostrandosi partner
amico e sensibile. a divulgarne il messaggio e le importanti atiivita svol’le ‘

dall’associazlone. SOSUShlll

 

 

 

 

Source: Personal Photos, Bologna, Italy, October 2008 .

*The translation of text in the upper half of the advertisement reads: SOSUShl Test. You’ve never tasted
sushi? Aren’t you curious? Present this coupon at the Sosushi laboratory in Bologna. Taste our specralty
while helping Komen Italia. This way you can eat eat, eat Sosushi and in domg so make an important .
contribution to women’s health! By choosing an item from the pink menu, you help support Komen Italia.

227

Sosushi donates 2 euros for every pink menu item purchased. The ﬁmds support projects in the struggle
against breast cancer. The translation of the lower half of the text reads: Sosushi and Komen Italia are
working together in the struggle against breast cancer. Sosushi, always in touch with the feminine universe,
decided to make a concrete effort on the ground for Komen Italia (www.komen.it), an association that
operates all over the world, known for its concrete engagement for the prevention of and in the struggle
against breast cancer, an illness that affects 36,000 women a year in Italy. The team of Sosushi, with
numerous fundraising initiatives, like the Pink Menu and charity dinners, will donate at least 10,000 euros
to Komen ltalia by September 1, 2009. Besides Sosushi supporting and sponsoring the “Race for the Cure”
run that Komen Italia organizes every year in Rome, Bari, and now in Bologna (on September 28th in the
Margharita Gardens), we have also pledged, as a sensitive partner and friend to the association, to spread
the important message of Komen Italia.

SGKC and the Avon Foundation are, of course, not only expanding cause-related
marketing in Italy and Puerto Rico. Breast cancer cause-related marketing campaigns are
developing all over the world through these organizations. For example, in Bulgaria,

Popular television star, Natalia Simeonova was announced as Avon Bulgaria’s
new breast cancer crusade spokesperson, and she introduced the alliance between
Avon and United Colors of Benetton in creating a pink t-shirt to beneﬁt the breast
cancer cause (Avon Foundation 2007).
Additionally, Avon India reported tremendous success with its Kiss Goodbye to Breast
Cancer campaign in 2005. According to the organization’s website, “The month-long
campaign in 2005 raised over 5,000 US dollars, selling more than 90,000 lipsticks”
(Avon Foundation 2006). SGKC, rather than directly initiating cause-related marketing
campaigns in countries without SGKC affiliates, teaches advocates about Komen’s brand
of advocacy via the Course for the Cure, which is currently active in ten countries.
According to Sara Friedman of SGKC, the Course for the Cure
has a ﬁmdraising component, talking about how they can learn to raise funds
through you know, connecting events, doing corporate sponsorship, grant writing,
and cause-related marketing campaigns, of course (my emphasis, Telephone
Interview, November 16, 2008).

Therefore, while cause-related marketing may be culturally unfamiliar at ﬁrst and may

still be shunned as a lesser form of advocacy by some NGOS, SGKC and the Avon

228

Foundation are largely experiencing success in transplanting cause-related marketing
advocacy strategies internationally.

GLOBAL PROLIFERATION OF BREAST CANCER CAUSE-RELATED
MARKETING

Although in some countries, SGKC and the Avon Foundation are directly involved in
leading the cause—related marketing trend, in other countries, particularly Western
European countries, companies and other breast cancer NGOS have adopted this trend
from US breast cancer organizations on their own. As Kathleen McDonald, an advocate

with Europa Donna in Ireland, described Breast Cancer Awareness Month in Ireland,

There are all sorts of things happening now, you have, like one of our department
stores had a pink party and they had a whole lot of pink things, everything from
balloons decorating the place in pink to pink night dresses, pink purses, pink
gloves, pink umbrellas, and you see this all over the place and sometimes it might
be to raise funds for the Cancer Society, other times it might be for the Mary
Kettering Foundation, but there is a plethora of these kinds of things that different
companies initiate and every year seems to spawn a few more and they all seem to
have the basic. . .of something in pink (Telephone Interview, October 15, 2008).

As her description shows, while SGKC and the Avon Foundation pioneered cause-related
marketing in the US and are directly expanding it as an advocacy technique globally, in
some cases corporations have adopted the marketing technique without urging from these
organizations.

Another example of such marketing is the international expansion of Fashion
Targets Breast Cancer (F TBC). Fashion Targets Breast Cancer is an NGO founded by the
Council of Fashion Designers of America (CFDA) in the US in 1994. According to the

organization’s literature,

Fashion Targets Breast Cancer is the US. fashion industry’s response to breast
cancer - a widely recognized effort that raises public awareness and funds to

229

support breast cancer research, education, screening and patient care. The
campaign has become an ongoing initiative of the CFDA Foundations - the
philanthropic division of the Council of Fashion Designers of America (CFDA),
which represents over 300 of America’s leading fashion designers. Since its
launch, Fashion Targets Breast Cancer has become the worldwide fashion
community ’s singular and most successﬁtl response to breast cancer - an issue of
vital importance to its primary consumers: women (my emphasis, F TBC 2009).

Like other companies that engage in breast cancer cause-related marketing, the CFDA
recognizes breast cancer as an important issue to its largely female consumer-base.
Although the US fashion industry developed FTBC, given the global nature of
corporations, it was in the interest of the fashion designers, who sell their clothes
internationally, to extend the FTBC campaign to other countries. To do this,
The CF DA Foundation licenses the Fashion Targets Breast Cancer name and logo
to leading breast cancer organizations in individual countries. The CFDA
Foundation recommends that approximately one-third of the proceeds from
merchandise sales accrue to the charity beneﬁciary (F TBC 2009).
F TBC campaigns currently operate in about ten countries, promoting cause-related
marketing to raise funds for breast cancer during BCAM (F TBC 2009). Table 8.1
delineates the international expansion of FTBC. Through this expansion, FTBC, like
SGKC and the Avon Foundation, is globally expanding a form of corporate- and
consumer-based breast cancer advocacy, which is an unfamiliar concept in many
countries. For example, F TBC unsuccessfully launched its campaign in Japan in 2003, as
stated by the NGO on their website,
F TBC Japan was launched in the spring of 2003, featuring world renowned
model, Ai Tominaga, and beneﬁting the Japan Cancer Society. At the time, the
concept of philanthropic sales of merchandise was new to Japan. However, in

recent years, Japanese women have begun to embrace this new approach to a
public health concern (my emphasis, FTBC 2009).

230

 

 

While the F TBC cancelled the campaign after the unsuccessful 2003 launch, it was re-
launched in 2008 as there seemed to be a shift in which Japanese women, unsupportive of
this unfamiliar form of advocacy only a few years ago, are now more receptive to it. Part
of the reason for this shift in acceptance may have been the increasing cause-related
marketing activities of the Avon Foundation in Japan from 2005 to 2008, with their Walk
Around the World for Breast Cancer events and cause-related marketing campaigns.
Perhaps, as in Italy where Komen Italia’s brand of corporate advocacy was initially
foreign, but increasingly accepted with repeated exposure, Japanese women have adapted
to this “new approach to a public health concern” (FTBC 2009).

Table 8.1. lntemational Expansion of Fashion Targets Breast Cancer Cause-Related
Marketig Campaign“

Country Year Established Funds Raised Allocation of
Funds
United States 1994 $40 million raised by all Not speciﬁed
campaigns (US and
international) combined
Brazil 1995 Not speciﬁed Instituto
Brasileiro de
Controlo do
Cancer (IBCC)

 

 

 

 

United Kingdom 1996 9.5 million pounds Breakthrough
Breast Cancer-a
breast cancer
NGO

Canada 2001 $750,000 (as of 2006) Rethink Breast
Cancer-
innovative breast
cancer education,
research and

support programs

 

 

 

 

 

 

 

231

Table 8.] (Continued)

Greece 2001 Not speciﬁed Inaugurated a Breast
Cancer Centre
dedicated to provide
free breast cancer
screening to women
ages 45-64.

All running costs,
salaries and
equipment are
funded by FTBC
Greece. The next
goal is to equip the
Center with a state-
of-the-art Digital

 

 

Mammography Unit.
Japan 2003 (cancelled due to Not speciﬁed Japan Cancer
lack of interest and re- Society; free
launched in 2008) mammograms at
launch of FTBC

event; raise public
awareness support
breast cancer
research, education,
screening and patient

 

 

care in Japan
Ireland 2005 287,000 euro (as of Irish Cancer Society
2007) and Europa Donna
Ireland
Australia 2005 $20 million Support new

research into young
women diagnosed
with breast cancer
Portugal 2006 500,000 euro Funding the ﬁght
against breast cancer
in Portugal

 

 

 

 

 

 

 

Source: Fashion Targets Breast Cancer (F TBC 2009)
*Turkey and Cyprus were also mentioned on the website as having FTBC programs, but no speciﬁcs were
provided.

Therefore, in addition to the efforts of SGKC and the Avon Foundation, other
organizations and corporations are implementing cause-related marketing campaigns
internationally. Although corporate advocacy is at times initially culturally unfamiliar, as

cause-related marketing strategies proliferate and persist, it seems that these campaigns

232

are becoming successful even in countries where they initially faltered only a few years
ago.
THE ALLOCATION OF FUNDS

While cause-related marketing campaigns beneﬁt participating corporations by
developing brand recognition and loyalty, potentially increasing their proﬁt, a portion of
funds amassed through corporate advocacy are allocated to “support the cause” in some
way. I found that the allocation of breast-cancer related cause-marketing funds largely
beneﬁt established biomedical NGOs as well as medical researchers, pharmaceutical and
medical technology companies, and cancer research centers, thereby strengthening the
biomedical approach to breast cancer.

Although a variety of NGOS addressing breast cancer often exist within a country,
the larger, more well-established NGOs receive more funding from cause-related
marketing campaigns. As described by Gabriella Lopez, the Avon representative in
charge of the breast cancer crusade at Avon Puerto Rico,

So they [Avon associates] receive this brochure and they can order products from

here so they have a way to demo to the customers and we also include the breast

cancer products right over here. We have plenty of products, necklaces, lip balm,
um, overnight treatment for the foots [sic], fragrance and socks. One hundred
percent of the net income of these products is going to the breast cancer crusade
and then this money stays in Puerto Rico. We donate this money to Sociedad

Americana del Cancer and this year we are adding one, another organization, and

that is Susan G. Komen (Personal Interview, Caguas, Puerto Rico, September 14,

2007)

While smaller breast cancer NGOS, such as Mujeres sin T tempo, that provide patient
services, such as transportation to and from doctor’s appointments or chemotherapy,

advice regarding healthcare coverage, and individual and family counseling services,

exist in Puerto Rico, the Avon Foundation donates funds to the two largest and most

233

ﬁnancially successful breast cancer-related non-proﬁts, namely the American Cancer
Society of Puerto Rico and, more recently, Komen Puerto Rico. Gabriella Lopez
explained the selection of organizations as based on the organizations’ ability to improve
the lives of individual women who are confronting breast cancer. In her words,
With this money the American Cancer Society, they have a program that they use
the money to give mammographies [mammograms] to women that ask for it.
They have ﬁve offices around the island and the person, the only thing that she
needs to do is go to his [her] doctor, the doctor gave the order to make the
mammography, and then she with that order go to the American Cancer Society,
they give you like a check or coupon and then she goes with that coupon back, it’s
the way that she pays to do the mammography (Personal Interview, Caguas,
Puerto Rico, September 14, 2007).
Although the American Cancer Society of Puerto Rico provides access to free screening
for Puerto Rican women, they do not actually provide services to women who have breast
cancer. Gabriella Lopez speciﬁcally stated that the Avon Foundation did not previously
donate to Komen Puerto Rico because Komen mainly funds medical research, which does
not immediately help women who have breast cancer. Despite this comment, she said that
they do not donate to smaller organizations because these organizations do not have the
resources to help women as much as do the larger organizations, reinforcing the ﬁnancial
success of elite organizations at the expense of grassroots organizations. Breast cancer
NGOS like Mujeres sin T iempo in Puerto Rico and Europa Donna have trouble
ﬁnancially sustaining themselves and may not attract large donations due to lack of status

and name-recognition, as with Mujeres sin T tempo, or because of cultural norms that are

not conducive to donating to NGOS, as with Europa Donna in Italy.

234

Table 8.2. Avon Foundation’s and SGKC’s Allocation of Funds Internationally

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Organization Country Allocation of Funds

Avon Argentina Purchase of mobile mammography unit; Donation to local
NGO to maintain and operate the unit

Avon Australia Local NGOs; Clinical trial research program; Community
support through exercise and counseling

Avon Bosnia Purchase of digital mammography machine for a medical
clinic

Avon Canada Donation to local NGO

Avon Czech Donation to local NGOS for screening tests, rehabilitation

Republic treatment, purchase of medical devices, educational

brochures, and to help fund the operation of a toll-free breast
cancer help line

Avon Dominican Donation to local NGOS for early detection tests, medical

Republic treatment, and support groups for underserved cancer patients;

Donation to hospitals that provide care for cancer patients

Avon Ecuador Donation to local NGO; Purchase of early detection
equipment for medical centers

Avon El Salvador Funds to equip a pathology lab; Funds to provide care for
low-income cancematients

Avon El Salvador Donation to the National Cancer League

Avon Estonia Donation to local NGO; purchase of new mammography bus;
Funding for breast cancer detection and treatment;

Avon Finland Donation to local NGO; Funding for medical research

Avon France Donation to breast cancer research center; Funding for
medical research

Avon Germany Donation to local cancer society for help for breast cancer
patients who need ﬁnancial assistance; Donation to local
NGO

Avon Greece Purchase of mobile mammography unit

Avon Guatemala Donation to National Cancer Society

Avon Hungary Donation to the National Health Service and a local NGO;
Purchase of mobile mammography van and surgical
equipment for medical centers and institutions including the
National Oncology Institution, Szent Istvan Hospital and the
National Medical Center, Uzsoki Hospital; Funding for breast
reconstruction operations

Avon India Donation to the Cancer Patients Aid Association for the
purchase of a van and free shuttle service for cancer patients

Avon Italy Donation to the European Institute of Oncology

Avon Latvia Donation of gamma detector equipment to the Latvia
Oncology Center

Avon Lithuania Donation of mammography machine to the National Institute
of Oncology; Donation to the Vilius University Oncology
Institute to purchase equipment for breast cancer Enosis

Avon Macedonia Free breast exams throughout Avon events

Avon Malaysia Creation of breast prosthesis fund at the University Malay
Medical Center; Donated a Breast Cancer Resource Center to
the University Malay Medical Center; Donation to the Breast
Cancer Welfare Association; Funding of 25 health education
workshops

 

235

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table 8.2 (Continued)
Avon Mexico Donation to a wide range of institutes that provide support
for cancer research, treatment, and early detection programs
Avon Oman Donation to the National Association for Cancer Awareness
Avon Philippines Upgraded breast care services at various provincial
hospitals and Manila’s Philippine General Hospital;
Donation to PGH Breast Care Center and two government
hospitals; Donation of ultrasound machines for two
government hospitals and salaries and supplies at the PGH
Breast Cancer Center
Avon Poland Free breast exams thwhout Avon events
Avon Portugal Donation of digital mammography machine to hospitais da
Universidade de Coimbra, a local hospital (Avon Portugal’s
third equipment donation since 2002)
Avon Romania Information Not Available
Avon Russia Purchase of contemporary screening and diagnostic
ermipment across Russia
Avon Slovenia Purchase of medical devices for breast reconstruction after
mastectomy-donated to the Clinical Center Ljubljana
Avon South Africa Donation to Bosom Buddies (breast cancer suppoﬂroup)
Avon Spain Donation of more than $350,000 to Project Avon, a
partnership for breast cancer research that it founded with
the Scientiﬁc Foundation of the Spanish Association
Against Cancer
Avon Turkey Donation of mammography machine
Avon Ukraine Purchase of diagnostic equipment for breast cancer
screening; mobile mammography van
Avon United Arab Funding for breast cancer research and awareness
Emirates
Avon United Kingdom Donation to establish the Breakthrough Toby Robins Breast
Cancer Research Center (the ﬁrst breast cancer research
facility in the UK); Purchase of new MRI scanner for the
Breast Screening Department at Kettering General Hospital;
Study on genetic and hormonal risk factors
Avon Venezuela Investment in four low-cost breast cancer clinics in
Carabobo state
SGKC United States Breast cancer research grants to 43 institutions in 13
countries outside of the US; establishment of international
afﬁliates in Germany, Italy and Puerto Rico
SGKC Mexico Funding for medical research and clinical resources
SGKC Global Promise Grants to NGOs to develop and implement breast health
Fund (provides and breast cancer programs and services
ﬁinds to other
countries)
SGKC Global Expansion Funding of educational program to teach fundraising and
Program (Mexico, awareness raising advocacy strategies
Costa Rico,
Panama, Brazil,
Saudi Arabia,
Jordan, UAE,
Ghana, Romania,
Ukraine)

 

 

 

 

236

 

 

 

 

Table 8.2 (Continued)
SGKC Italy Donation to cancer center/hospital; Support for young
researchers, scientists, cancer centers, educational pggrams
SGKC Puerto Rico Grant program to fund local breast cancer education,
screening and patient support programs
SGKC Bahamas Funding cancer research in the Bahamas

 

 

 

 

 

Source: Compilation of data from www.komen.org; www.avonfoundation.org; www.komenpr.org;
www.komen.it

As shown in Table 8.2, the majority of funds garnered through Avon’s and
SGKC’s cause-related marketing campaigns support biomedical breast cancer research or
the purchase of medical technologies. The Avon Foundation, due to its partnerships with
local governmental and/or non-governmental organizations in the international locations
where it operates, donates funds to a local governmental or non-governmental
organization, but often for a speciﬁc breast cancer-related medical technology purchase.
For example, “the primary goal of” Avon Estonia’s fundraising campaigns in 2008 “was
to raise money for new mammography equipment” (Avon 2008). Although some of the
funding is allocated for breast cancer education programs and patient services, the
majority is spent on medical equipment and ﬁmneled into biomedical research projects.

The allocation of funds raised internationally by SGKC and the Avon Foundation
through the expansion of their corporate advocacy programs demonstrates the role that
biomedical health advocacy organizations can play in the global political economy of
health and illness. These organizations are ﬁnancially supporting a biomedical approach
to breast cancer, and in doing so on an international scale are often aiding the market
expansion of pharmaceutical and medical technology companies as well as creating

opportunities for increased international breast cancer research.

CONCLUSION

Political opportunity scholars have addressed the ability of social movements to create

opportunities. That is, in addition to responding to exogenous opportunities, collective

237

action groups have the potential to create or restrain opportunities for allies,
countermovements, and other social groups that may be affected by the movement’s
activities. The creation or restraint of other social actors’ opportunities may be purposeful
or unintentional. Through their global expansion of corporate advocacy, via cause-related
marketing, SGKC and the Avon Foundation have potentially hindered the opportunities
of smaller, grassroots breast cancer organizations, while expanding opportunities for
other established organizations (e.g., LILT in Italy). At the same time, SGKC and the
Avon Foundation are expanding opportunities for corporations, particularly with regard
to multinational corporate expansion through cause-marketing campaigns (e.g., the global
expansion of clothing brands via the CFDA’s Fashion Targets Breast Cancer campaign).
Through their global expansion of corporate advocacy strategies, SGKC and the
Avon Foundation are once again demonstrating how social movements can act as
globalizing agents. These advocacy organizations are promoting a type of corporate
advocacy, which by necessity, creates consumer advocates around the world. Despite
initial resistance in some expansion locations (e.g., Italy, Japan), these organizations have
managed to persist, due to their signiﬁcant organizational and ﬁnancial resources,
eventually gaining social acceptance and participation. In addition to globally expanding
a form of advocacy (i.e., cause-related marketing campaigns), SGKC and the Avon
Foundation are promoting a new type of advocacy in which corporations participate
through the marketing of cause-related products and sponsorship of advocacy events and
consumers participate by purchasing cause-related products and participating in

corporate-sponsored events.

238

 

Finally, the global promotion of this type of advocacy is signiﬁcant with regard to
the global political economy of health and illness. As discussed by Clarke and her
colleagues (2005, 446), the “political economy of biomedicalization consists of
multinational corporations that are spreading the biomedical paradigm and processes of
biomedicalization around the world,” promoting “solutions to health problems [that] are
increasingly corporatized and commodiﬁed.” By expanding corporate- and consumer-
advocacy solutions to breast cancer, these organizations are active participants in the
political economy of biomedicalization. In addition to multinational corporations,
biomedical health advocacy organizations are actors in defming how health problems are
deﬁned, and thereby, how they can be solved. By funding pharmaceutical and medical
technology companies, rather than channeling funds to public health programs, SGKC
and the Avon Foundation are furthering “corporatized” and “commodiﬁed” solutions to

global health problems.

239

CHAPTER 9
CONCLUSIONS

In Chapter 1, I stated that literature on the global expansion of breast cancer advocacy
was generally lacking and particularly lacking with regard to engagement with social
movement and health and illness theories. My dissertation research begins to ﬁll this gap
in the literature. By examining the global expansion of biomedical breast cancer
advocacy, via SGKC and the Avon Foundation, in light of social movement and health

and illness theories, I conclude in this chapter with my contributions to these literatures.

THEORETICAL IMPLICATIONS

As I stated in Chapter 1, deﬁnitions of social movements vary in terms of speciﬁcs, social
movements are generally understood as collectivities acting at least partially outside of
formal institutional channels, with some degree of organization and continuity, for the
purpose of “challenging or defending extant authority, whether it is institutionally or
culturally based, in the group, organization, society, culture or world order of which they
are a part” (Snow et al. 2004, 11). Health social movements in particular have mobilized
to challenge medical policy, public health policy and politics, belief systems, medical
research and medical practices (Brown 2005, 1). Within the context of globalization,
transnational social movements are primarily noted for the challenges they have posed to
neoliberal proliferation, environmental degradation, human rights’ violations, crimes
against women, war, and misguided development programs (Reitan 2007; Keck 1998;
della Porta 2005; Smith 2004). In most cases, therefore, transnational social movements

position themselves in opposition to global neoliberal policies.

240

My inclusion of elite and corporate organizations in the realm of “social
movements” is no doubt problematic to some. Nevertheless, I propose that our
understanding of social movements needs to evolve as forms of advocacy evolve. By
understanding SGKC and the Avon Foundation as forms of “corporate philanthropy,” as
Samantha King does, we might miss important opportunities to better understand trends
in advocacy, or speciﬁcally in this case, trends in health advocacy. As the literature on
transnational social movements demonstrated, a bias toward left-leaning and grassroots
movements exists in much social movement scholarship. SGKC and the Avon
Foundation represent a case in which elite and corporate organizations are co-opting the
language of grassroots movements, while promoting their agendas with the full force of
their organizational and ﬁnancial resources. While these organizations are co-opting the
language of grassroots social movements that is not to say that they are not advocacy
organizations, or should not be understood as social movements in their own right.

In fact, these organizations are promoting a form of corporate- and consumer-based
advocacy, which has not only become an increasing trend in the US (e. g., in health,
environmental, and organic movements), but is now expanding globally through these
organizations, seemingly fairly rapidly and successfully. It is important, therefore, for
social movement scholars not only to focus on movements that challenge broad social
trends, like neoliberal globalization, but also to address movements that complement
neoliberal trends, as SGKC and the Avon Foundation do by promoting individual and
corporate solutions to breast cancer.

Biomedical breast cancer advocacy organizations also challenge most

understandings of social movements by blurring boundaries between, previously thought

241

of as distinct, social sectors. SGKC and the Avon Foundation demonstrate how elite and
corporate advocacy organizations are able to partner with governmental, medical, and
corporate sectors, oﬁen creating hybridizations of the non-governmental sector and these
other entities. Particularly in the development of corporate advocacy, which is the most
prominent hybridization of sectors, utilized by SGKC and the Avon Foundation, these
organizations are redeﬁning what “counts” as advocacy not only in the US, but globally
as well. Finally, by expanding particular forms of advocacy and processes of
biomedicalization, SGKC and the Avon Foundation demonstrate the importance of
recognizing social movements as not only responding to globalization, but also as agents
of globalization in their own right.

The global expansion of biomedical breast cancer advocacy plays a signiﬁcant
role in the global political economy of health and illness, as evidenced by my research
ﬁndings. Beginning with the global expansion of biomedical breast cancer advocacy
organizations in the upper right of the ﬁgure and then following the arrows clockwise, I
visually display my understanding of the process of the global expansion of biomedical
breast cancer advocacy organizations. Because these organizations pursued international
markets, they socially constructed a global breast cancer crisis to legitimize their
expansion. By socially constructing a global breast cancer crisis and promoting messages
of awareness and disseminating information about breast cancer risk, these organizations
began contributing to the creation of “at-risk” identities. Additionally, by advancing
corporate advocacy and cause-related marketing campaigns, these organizations

promoted corporate- and consumer-advocate identities. By promoting

242

“potentially at-risk” identities to advocacy event participants and through educational
materials and media campaigns, while arguing that the solution to breast cancer lies in
biomedical research, pharmaceutical and medical technological developments, SGKC
and the Avon Foundation also created new “biomedical consumers.” These biomedical
consumers, through consumer-advocacy, support the allocation of funds to biomedical
research, pharmaceutical and medical technology companies. These are the same medical
research centers, pharmaceutical and medical technology companies that then fund and
participate in biomedical breast cancer events and campaigns, thereby completing the
circle in the ﬁgure and demonstrating how biomedical advocacy perpetuates itself in the
global political economy of health and illness, largely due to the support of biomedical

advocacy organizations.

PRACTICAL IMPLICATIONS

As discussed in Chapter 1, there is an increasing trend in disease-speciﬁc biomedical
health advocacy in the US. With the ﬁnancial success of biomedical breast cancer
advocacy, other health advocates are embracing a similar form of disease-speciﬁc
advocacy and adopting similar programs of awareness-raising events, corporate-advocate
partnerships, and cause-related marketing campaigns. Examples of this can be seen
around such diseases as ovarian cancer, heart disease in women, testicular cancer, and
spinal muscular atrophy. This form of advocacy, rather than addressing healthcare access
and equity on a national or international level, raises awareness about a particular disease,
placing it in competition with other diseases for media attention, ﬁnancial resources, and

ultimately, medical attention. As this form of advocacy expands beyond the US, members

243

 

of such groups are joining other actors in shaping the global political economy of health
and illness by promoting individual and corporate solutions to health problems.

It is highly questionable whether this type advocacy will actually improve
people’s health. Even in the US, with a 25-year history of breast cancer advocacy,
awareness-raising, and fundraising, the breast cancer mortality rate just recently began to
decrease slightly and treatment regimens have changed minimally. The main change has
been in the increasing number of pharmaceutical interventions in the treatment and/or
prevention of breast cancer, which have had mixed results (Klawiter 2002). Lack of
access to health insurance and care remain the main factors contributing to late-stage
diagnosis and mortality from breast cancer in the US.

Therefore, while SGKC and the Avon Foundation tout their success in combating
breast cancer in the US, it has not been made clear that awareness, education, and
increased funding of biomedical treatments and interventions are the best way to address
breast cancer. By proposing individual solutions to global health inequalities (e.g., by
providing free breast cancer screening at events), these organizations omit any critique of
the state of access to healthcare in the locations to which they have expanded. By
emphasizing awareness, education, and individual responsibility, particularly in countries
where not only is there inequality with regard to healthcare, but where there may not be
sufﬁcient healthcare infrastructure to adequately diagnose and treat breast cancer, these
organizations may be creating educated medical-consumers who lack the resources to be

treated if they found that they had the disease (WHO 2008).

244

 

 

 

APPENDIX

Interview Guide

International Breast Cancer Advocates

1. Name
2. Sex
3. Race/ethnicity
4. Age
5. Education level (degrees)
6. Current work and/or educational status
7. How did you get involved in this organization?
8. How long have you been working with this organization?
9. How long has this organization existed in (location)?
10. What prompted its development?
11. Have you been involved with this organization since its inception?
12. What is the primary focus of this organization?
13. Are there any other organizations that have a similar focus?
a. If so, which organizations?
14. What types of activities/events does this organization sponsor or take part in?
15. How have your events and projects been received?

a. Turnout?
b. What types of responses have you gotten from the public?

16. Do you partner with any other organizations?

a. If so, how and why did the partnership develop?

245

 

b. Which organizations?
c. What types of things do you do together?

17. Have there been any alliances or conﬂicts with other health organizations?
a. If so, regarding what?

18. Does your organization have corporate sponsors?
a. If so, which corporations?
b. How did this come about?

0. What role do corporate sponsors/donors play in your organization?

19. Are you familiar with the Susan G. Komen for the Cure Foundation, the Avon
Breast Cancer Crusade, or the Breast Health Global Initiative?

a. If so, what are your perceptions of these organizations?

20. Have you or anyone from your organization attended international breast cancer
summits/conferences?

a. If so, which ones, where, what was the focus, what did you get out of
attending?
21. Is breast cancer a government health priority in (location)?
a. Is it a health priority for women in (location)?
22. Are there other women’s health issues that are of particular concern?

a. If so, like what?
b. Is there advocacy/activism around that health issue?

23. Is there a stigma surrounding breast cancer?
24. When did the pink ribbon symbol begin to appear in (location)?
25. Are there ads about breast cancer in magazines, on billboards, on TV?

a. If so, when did this start?
b. Who sponsors the ads?

26. Is there a breast cancer awareness month?

a. Which month?

246

 

27. What Ianguage(s) is information about breast cancer presented in?

Participants at International Breast Cancer Summits
1. Name
2. Sex
3. Race/ethnicity
4. Age
5. Education level (degrees)
6. Current work and/or educational status
7. US. delegate or international delegate
a. If international, what country?
8. What brought you to this summit?

9. Are you affiliated with SGKC, the Avon Foundation, the Global Breast Health
Initiative

a. If so, how and why?
b. For how long?

10. With any other breast cancer organization?
a. If so, which one(s)?

11. In your view, what was the purpose/goal of this summit?
a. Was this goal met?

12. What did you do at the summit?

13. What came out of the summit?

14. What will you do regarding breast cancer in your country after attending the
summit?

15. (If not US delegate) Is breast cancer a national health priority in your country?

247

 

Advocates involved in initiating the global expansion

10.

ll.

12.

13.

14.

15.

16.

17.

. Name

Sex
Race/ethnicity
Age
Education level (degrees)
Current work and/or educational status
How did you get involved in this organization?
How long have you been working with this organization?
How long has this organization existed?
What prompted its development?
Have you been involved with this organization since its inception?
What is the primary focus of this organization?
Are there any other organizations that have a similar focus?
a. If so, which organizations?
What types of activities/events does this organization sponsor or take part in?
How have your events and projects been received?

a. Turnout?
b. What types of responses have you gotten from the public?

Do you partner with any other organizations?
a. If so, how did the partnership develop?
b. Which organizations?

0. What types of things do you do together?

Have there been any alliances or conﬂicts with other health organizations?

248

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

a. If so, regarding what?

Does your organization have corporate sponsors?
a. If so, which corporations?
b. How did this come about?

c. What role do corporate sponsors/donors play in your organization?

Have you or anyone from your organization attended international breast cancer
summits/conferences?

a. If so, which ones, where, what was the focus, what did you get out of
attending?

What prompted the decision to expand this organization beyond the US?
When was this decision made?

Who was involved in making the decision?

How were the expansion locations chosen?

How are the international afﬁliates set up?

What is the relationship between the US. afﬁliates and the international
afﬁliates?

What forms of advocacy are promoted globally?
a. How was this decided upon?
Are there further plans for including more countries?

a. Which countries?
b. How was this decision made?

Advocates involved in local breast cancer NGOS

l.

2.

Name
Sex
Race/ethnicity

Age

249

10.

ll.

12.

13

14.

15.

16.

17.

18.

Education level (degrees)

Current work and/or educational status

How did you get involved in this organization?

How long have you been working here?

How long has this organization existed in (location)?

What prompted its development?

Have you been involved with this organization since its inception?

What is the primary focus of this organization?

. Are there any other organizations that have a similar focus?

a. If so, which organizations?
What types of activities/events does this organization sponsor or take part in?

Do you partner with any other organizations?
a. If so, how did the partnership develop?
b. Which organizations?
0. What types of things do you do together?
Have there been any alliances or conﬂicts with other health organizations?
a. If so, regarding what?

Does your organization have corporate sponsors?

a. If so, which corporations?
b. How did this come about?

Are you familiar with the Susan G. Komen for the Cure Foundation, theAvon
Breast Cancer Crusade, and/or the Breast Health Global Initiative?

a. If so, what are your perceptions of these organizations?

19. Have you or anyone from your organization attended international breast cancer

summits/conferences?

250

 

a. If so, which ones, where, what was the focus, what did you get out of
attending?

20. Is breast cancer a government health priority in (location)?
a. Is it a health priority for women in (location)?
21. Are there other women’s health issues that are of particular concern?

a. If so, like what?
b. Is there advocacy/activism around that health issue?

22. Is there a stigma surrounding breast cancer?
23. When did the pink ribbon symbol begin to appear in (location)?
24. Are there ads about breast cancer in magazines, on billboards, on TV?

a. If so, when did this start?
b. Who sponsors the ads?

25. Is there a breast cancer awareness month?
a. Which month?

26. What language is information about breast cancer presented in?

251

REFERENCES

Allsop, Judith, Kathryn Jones, and Rob Baggott. 2005. "Health Consumer Groups in the
UK: A new social movement?" Pp. 57-76 in Social Movements in Health, edited
by P. Brown and S. Zavestoski. Malden, MA: Blackwell Publishing.

Althuis, Michelle D. , Jaclyn M. Dozier, William F. Anderson, S.S. Devesa, and Louise
A. Brinton. 2005. "Global Trends in Breast Cancer Incidence and Mortality,
1973-1977." International Journal of Epidemiology 34:405-412.

Altman, Roberta. 1996. Waking Up, Fighting Back: The Politics of Breast Cancer.
Boston: Little, Brown and Company.

American, Cancer Society. 2006, "Breast Cancer Facts & Figures 2005-2006", Retrieved
May 30, 2009, (http://www.cancer.org/downloads/STT/CAFFZOOSBrF.pdf).

Andrews, Kenneth and Bob Edwards. 2004. "Advocacy Organizations in the US.
Political Process." Annual Review of Sociology 30:479-506.

Anglin, M.K. 1997a. "Working from the Inside Out: Implications of Breast Cancer
Acitivsm for Biomedical Politics and Practices." Social Science & Medicine
44:1403-1415.

Anglin, Mary K. 1997b. "Working From the Inside Out: Implications of Breast Cancer
Activism for Biomedical Politicies and Practices." Social Science of Medicine
44:1403-1415.

Annandale, Ellen. 2002. The Sociology of Health & Medicine: A Critical Introduction.
Malden, MA: Polity Press.

Aronowitz, Robert A. 2007. Unnatural History: Breast Cancer and American Society.
Cambridge: Cambridge University Press.

Avon, Foundation. 2005a, "50 Years: Avon Foundation News", Retrieved June 4, 2009,
(http://www.avoncompany.com/women/avonfoundation/newsletter_issue_3.pdf).

—. 2005b, "Avon Foundation 50th Anniversary Marked with Breast Cancer Events in
Nearly 40 Countries", Retrieved December 15, 2007,
(http://www.avoncompany.com/women/news/pressZOOS0826.htrnl).

—. 2005c. "Impact of the Avon Foundation Breast Cancer Crusade 1992-2005." Avon
Foundation.

—. 2006a, "Avon Foundation News", Retrieved January 15, 2008.

—. 2006b, "Fight Against Breast Cancer Goes Grassroots to Global: Annual Walk
Around the World for Breast Cancer Expands to 39 Countries Across Six
Continents", Retrieved January 15, 2008,
(http://www.avoncompany.com/women/news/pre5320060920.html).

252

—. 2006c, "Walk Around the World, Countries, India", Retrieved January 15, 2008,
(http://walk.avonfoundation.org/site/PageServer?pagename=Asia_India).

—. 2006d, "Walk Around the World, Countries, Ireland", Retrieved January 15, 2008,
(httpzl/walk.avonfoundation.org/site/PageServer?pagename=Euro_Irela).

—. 2007a, "Avon Walk Around the World for Breast Cancer", Retrieved May 30, 2009,
(http://walk.avonfoundation.org/site/PageServer?pagename=WorldWalk_Main).

—. 2007b, "Breast Cancer Welfare Association & Avon Malaysia: A Unique Corporate-
NGO Partnership of Reaching the Unreachable", Retrieved May 30, 2009,
(http://info.avonfoundation.org/site/News2?page=NewsArticle&id=24065&news
_iv_ctrl=-l ).

—. 2007c, "Breast Cancer Welfare Association & Avon Malaysia: A Unique Corporate-
NGO Partnership of Reaching the Unreachable", Retrieved January 15, 2008.

—. 2007d, "For Our Sisters' Health and Happiness: Avon China Launched KGBC
Campaign in 30 Cities on March 8", Retrieved January 15, 2008.

—. 2007c, "Walk Around the World, Countries, Brazil", Retrieved January 15, 2008,
(http://walk.avonfoundation.org/site/PageServer?pagename=Samer_Brazi).

—. 2007f, "Walk Around the World, Countries, Bulgaria", Retrieved January 15, 2008,
{http://walk.avonfoundation.org/site/PageServer?pagename=Euro_Bulga).

—. 2007g, "Walk Around the World, Countries, China", Retrieved May 15, 2009,
(http://walk.avonfoundation.org/site/PageServer?pagename=Asia_China).

—. 2007h, "Walk Around the World, Countries, Ecuador", Retrieved January 15, 2008,
(http://walk.avonfoundation.org/site/PageServer?pagename=Samer_Ecuad).

—. 2007i, "Walk Around the World, Countries, France", Retrieved January 15, 2008,
(http://walk.avonfoundation.org/site/PageServer?pagename=Euro_Franc).

—. 2007j, "Walk Around the World, Countries, Japan", 2008
(http://walk.avonfoundation.org/site/PageServer?pagename=Asia__Japan).

—. 2007k, "Walk Around the World, Countries, Malaysia", Retrieved January 15, 2008,
(http://walk.avonfoundation.org/site/PageServer?pagename=Asia_Malay).

—. 20071, "Walk Around the World, Countries, Romania", Retrieved January 15, 2008,
(http://walk.avonfoundation.org/site/PageServer?pagename=Euro_Romani).

—. 2007m, "Walk Around the World, Countries, South Africa", Retrieved January 15,
2008, (http://walk.avonfoundation.org/site/PageServer?pagename=Afri_safri).

253

—. 2008a, "Improving the Lives of Women Globally: Avon Foundation Impact Report
2007-2008", Retrieved May 15, 2009,
(http://www.avoncompany.com/women/avonfoundation/impactreport.pdf).

—. 2008b, "Walk Around the World, Countries, Estonia", Retrieved July 15, 2008,
(http://walk.avonfoundation.org/site/PageServer?pagename=Euro_Eston).

—. 2008c, "Walk Around the World, Countries, Thailand", Retrieved Janauary 15, 2008,
(http://walk.avonfoundation.org/site/PageServer?pagename=Asia_Thai).

—. 2008d, "Walk with Avon to Raise Money in the Fight Against Breast Cancer",
Retrieved January 15, 2009.

—. 2009, "Avon Foundation for Women Overview", Retrieved June 7, 2009,
(http://www.avoncompany.com/women/avonfoundation/overview.htrnl).

Babbie, Earl. 2004. The Practice of Social Research. Belmont, CA: Wadsworth.

Batt, Sharon. 1994. Patient No More: The Politics of Breast Cancer. Charlottetown:
Gynergy.

Benford, Robert D. and David A. Snow. 2000. "Framing Processes and Social
Movements: An Overview and Assessment. " Annual Review of Sociology 26:61 1-
639.

Bennett, W. Lance. 2005. "Social movements beyond borders: Understanding two eras of
transnational activism." Pp. 203-226 in Transnational Protest and Global
Activism, edited by D. Della Porta and S. Tarrow. New York: Rowman &
Littleﬁeld.

Berg, Bruce L. 2004a. Qualitative Research Methods for the Social Sciences. Boston:
Pearson.

BHGI. 2008a, "Breast Health Global Initiative: Mission and Principles", Retrieved
February 13, 2008
(http://www.fhcrc.org/soience/phs/bhgi/organization/mission.htrnl).

—. 2008b. "Interview with Sally Wellington, BHGI Member."

—. 2008c, "Report from the Breast Health Global Initiative", Retrieved January 20,
2009,
(http://www.ﬂrcrc.org/sciencelphs/bhgi/news/Z008/BHGI_Report_2008.pdf).

—. 2008d, "Who We Are", Retrieved January 15, 2009,
(http://www.fhcrc.org/science/phs/bhgi/organization/index.html).

254

 

 

—. 2009, "BHGI Guidelines for lntemational Breast Health and Cancer Control",
Retrieved June 10, 2009,
(http://www.fhcrc.org/science/phs/bhgi/guidelines/index.html#2002).

Blaikie, N. 2000. Designing Social Research. Cambridge: Polity Press.

Brenner, Barbara. 2000a. "Sister Support: Women Create a Breast Cancer Movement."
Pp. 325-354 in Breast Cancer: Society Shapes an Epidemic, edited by A. S.
Kasper and S. J. Ferguson. New York: St. Martin's Press.

Brenner, Barbara A. 2000b. "Sister Support: Women Create a Breast Cancer Movement."
Pp. 325-354 in Breast Cancer: Society Shapes an Epidemic, edited by A. S.
Kasper and S. J. Ferguson. New York: St. Martin's Press.

Brody, Julia and Ruthann A. Rudel. 2003. "Environmental Pollutants and Breast Cancer."
Environmental Health Perspectives 11 1:1007-1019.

Brody, Julia, Joel Tickner, and Ruthann A. Rudel. 2005. "Commurrity-Initiated Breast
Cancer and Environment Studies and the Precautionary Principle." Environmental
Health Perspectives 1 13:920-925.

Brown, Phil. 1995. "Naming and Framing: The Social Construction of Diagnosis and
Illness." Journal of Health and Social Behaviorz34-52.

—. 2000. Perspectives in Medical Sociology. Prospect Heights: Waveland Press.

—. 2002. "Preface to Special Issue on Environmental Health." The Annals of the
American Academy 584:7-12.

Brown, Phil, Sabrina McCormick, Brian Mayer, Stephen Zavestoski, Rachel Morello-
Frosch, Rebecca Glasior Altman, and Laura Senier. 2006. ""A Lab of Our Own":
Environmental Causation of Breast Cancer and Challenges to the Dominant
Epidemiological Paradigm." Science, Technology & Human Values 31 :499-536.

Brown, Phil and Stephen Zavestoski. 2005. "Social Movements in Health: An
Introduction." Pp. 1-16 in Social Movements in Health, edited by P. Brown and S.
Zavestoski. Malden, MA: Blackwell Publishing.

Brown, Phil, Stephen Zavestoski, Sabrina McCormick, Brian Mayer, Rachel Morello-
Frosch, and Rebecca Gasior Altman. 2004. "Embodied Health Movements: New
Approaches to Social Movements in Health." Sociology of Health & Illness
26:50-80.

Buechler, SM. 2000. Social Movements in Advanced Capitalism: The Political Economy
and Cultural Construction of Activism. New York: Oxford University Press.

255

Bush, Laura. 2006. "Mrs. Bush's Remarks at the Susan G. Komen Breast Cancer
Foundation 2006 Mission Conference." edited by O. o. t. F. Lady. Washington
DC.

BusinessWeek. 2009a, "Executive Proﬁle: Andrea Slater", Retrieved June 9, 2009,
(http://investing.businessweek.com/businessweek/research/stocks/people/person.a
sp?personId=261 82886&ric=AVP&previousCapId=253 132&previousTitle=Avon
%20Products%201nc.).

—. 2009b, "Executive Proﬁle: Brian C. Connolly", Retrieved June 7, 2009,
(http://investing.businessweek.com/research/stocks/people/person.asp?personld=1
992035&ric=AVP).

Casamayou, Maureen Hogan. 2001a. The Politics of Breast Cancer. Washington, DC:
Georgetown University Press.

—. 2001b. The Politics of Breast Cancer. Washington, DC: Georgetown University
Press.

Casper, Monica J. and Adele E. Clarke. 1998. "Making the Pap Smear into the 'Right
Tool' for the Job: Cervical Cancer Screening in the USA, circa 1940-1995."
Social Studies of Science 28:255-290.

CDC. 2004, "Leading Causes of Death in Females, Hispanic Females, United States,
2004", Retrieved June 12, 2009, (http://www.cdc.gov/Women/lcod.htm).

Clarke, Adele E. and Virginia L. Olesen. 1999. "Revising, Diffracting, Acting." Pp. 3-48
in Revisioning Women, Health, and Healing, edited by A. E. Clarke and V. L.
Oleson. New York: Routledge.

Clarke, Adele E., Janet K. Shim, Laura Mamo, Jennifer Fosket, and Jennifer Fishman.
2005. "Biomedicalization: Technoscientiﬁc Transformations of Health, Illness
and US. Biomedicine." Pp. 3-22 in The Sociology of Health & Illness: Critical
Perspectives, edited by P. Conrad. New York: Worth Publishers.

Coalition, National Breast Cancer. 2009, "Department of Defense Breast Cancer
Research Program (DOD BCRP)", Retrieved March 23, 2009
(http://www.stopbreastcancer.org/index.php?option=com_content&task=view&id
=710).

Cockerham, William C. 2004. "Medical Sociology." Upper Saddle River: Pearson.

Cohen, David, Michael McCubbin, J ohanne Collin, and Guilheme Perodeau. 2005.
"Medications and the Pharmaceutical Industry." Pp. 275-287 in The Sociology of
Health & Illness: Critical Perspectives, edited by P. Conrad. New York: Worth
Publishers.

256

Conrad, Peter. 1992. "Medicalization and Social Control." Annual Review of Sociology
18.

—. 2005. The Sociology of Health & Illness: Critical Perspectives. New York: Worth
Publishers.

—. 2007. The Medicalization of Society: 0n the Transformation of Human Conditions
into T reatable Disorders. Baltimore: Johns Hopkins University.

Conrad, Peter and Joseph W. Schneider. 2005. "Professionalization, Monopoly, and the
Structure of Medical Practice." Pp. 170-176 in The Sociology of Health & Illness:
Critical Perspectives, edited by P. Conrad. New York: Worth Publishers.

Cowan, Ruth Schwartz. 2008. Heredity and Hope: The Case for Genetic Screening.
Cambridge, MA: Harvard University Press.

Creswell, J .W. 1999. Qualitative Inquiry and Research Design: Choosing Among Five
Traditions. Thousand Oaks, CA: Sage.

Defense, Department of. 2008, "Congretionally Directed Medical Research Programs",
2008 (http://mrmc-rad6.army.mil/bcrp/).

della Porta, Donatella and Sidney Tarrow. 2005a. "Transnational Processes and Social
Activism: An Introduction." Pp. 1-20 in Transnational Protest and Global
Activism, edited by D. Della Porta and S. Tarrow. New York: Rowman &
Littleﬁeld Publishers.

della Porta, Donatella and Sidney Tarrow. 2005b. "Transnational Protest and Global
Activism: People, Passions, and Power." Lanham, MD: Rowman & Littleﬁeld.

DeVauIt, Marjorie L. 1996. "Talking Back to Sociology: Distinctive Contributions of
Feminist Methodology." Annual Review of Sociology 22:29-50.

Doral, Bank. 2009, "Ruta Pink: The Road to Early Breast Cancer Detection", Retrieved
June 12, 2009, (http://www.rutapink.com/index.htrnl).

Education, Institute of lntemational. 2009, "Institute of lntemational Education-At a
Glance", Retrieved May 24, 2009,
(http://www.iiesf.org/new/IIE%20at%20a%20Glance%202009%20(sf).pdf).

Ehrenreich, Barbara and Deidre English. 1978. For Her Own Good: Two Centuries of the
Experts'Advice to Women. New York: Anchor Books.

Eisenstein, Zillah. 2001. Manmade Breast Cancers. Ithaca: Cornell University Press.

Eschle, Catherine. 2001. "Globalizing Civil Society? Social Movements and Challenge of
Global Politics from Below." Pp. 61-85 in Globalization and Social Movements,

257

edited by P. Hamel, H. Lustiger-Thaler, J. N. Pieterse, and S. Rosenail. New
York: Palgrave.

Evans, Peter. 2005. "Counterhegemonic Globalization: Transnational Social Movements
in the Contemporary Global Political Economy." Pp. 655-670 in The Handbook of
Political Sociology: States, Civil Societies, and Globalization, edited by T.
Janoski, R. Alford, A. Hicks, and M. Schwartz. Cambridge: Cambridge
University Press.

Farro, Antimo and Jean-Guy Vaillancourt. 2001. "Collective Movements and
Globalization." Pp. 206-226 in Globalization and Social Movements, edited by P.
Hamel, H. Lustiger—Thaler, J. N. Pieterse, and S. Rosenail. New York: Palgrave.

Ferguson, Susan J. 2000. "Deforrnities and Diseased: The Medicalization of Women's
Breasts." Pp. 25-50 in Breast Cancer: Society Shapes an Epidemic, edited by A.
S. Kasper and S. J. Ferguson. New York: St. Martin's Press.

Fernandez, S. 2005, "Pretty in Pink", 2007
(http://www.thinkbeforeyoupink.org/Pages/PrettyInPink.html).

Fetterman, Debbie. 2007, "After 25 years, Komen group still ﬁghting for a cure",
Retrieved June 5, 2009, ,
(http://www.dallasnews.com/sharedcontent/dws/fea/columnists/dfetterman/stories
/DN-nh_ﬁtcity__0403liv.ART.State.Editionl .20a240b.html).

Figert, Anne E. 1995. "The Three Faces of PMS: The Professional, Gendered and
Scientiﬁc Structuring of a Psychiatric Disorder." Social Problems 42:56-73.

Fishman, Jennifer. 2000. "Assessing Breast Cancer: Risk, Science, and Environmental
Activism in an "at risk" Community." Pp. 181-204 in Ideologies of Breast
Cancer: Feminist Perspectives, edited by L. Potts. New York: St. Martin's Press.

Fosket, Jennifer. 2004. "Constructing "Hight Risk Women": The Development and
Standardization of a Breast Cancer Risk Assessment Tool." Science, Technology
& Human Values 29:291-313.

Foucault, Michel. 1973. The Birth of the Clinic: An Archaeology of Medical Perception.
New York: Random House.

Foundation, Avon. 2008, "Avon Foundation History", Retrieved 20 February 2009.

FTBC. 2009a, "Fashion Targets Breast Cancer", Retrieved June 12, 2009,
(http://www.fashiontargetsbreastcancer.org/index.php?cmd=home).

—. 2009b, "Fashion Targets Breast Cancer Overview", Retrieved June 12, 2009.

258

 

—. 2009c, "Fashion Targets Breast Cancer: Japan", Retrieved June 12, 2009,

(httpzl/www.fashiontargetsbreastcancer.org/index.php?cmd=country&country_id
=4).

Giorgi, Daniela, Leonardo Ventura Giordano, Alfonso Frigerio, and Eugenio Paci. 2007.
"Mammography Screening in Italy: 2004 Survey and 2005 Preliminary Data."
Epidemiology of Prevention 31 :7-20.

Goodwin, Jeff and James M. Jasper. 1999. "Caught in a Winding, Snarling Vine: The
Structural Bias of Political Process Theory." Sociological Forum 14:27-54.

Government, Citizens for Honest. 2009, "The Pioneers: George W. Bush's $100,000
Club", Retrieved June 5, 2009,
(http://www.citizenforhonestgovernment.com/pioneer_proﬁles.htrn).

Haraway, Donna. 2004. "Situated Knowledges: The Science Question in Feminism and
the Privilege of Partial Perspective." Pp. 81-102 in The Feminist Standpoint
Reader: Intellectual and Political Controversies, edited by S. Harding. New York

London: Routledge.

Harding, Sandra. 2004. "Rethinking Standpoint Epistemology: What is "Strong
Objectivity?"." Pp. 127-140 in The Feminist Standpoint Theory Reader:
Intellectual and Political Controversies, edited by S. Harding. New York:
Routledge.

Hess, David. 2005. "Medical Modernisation, scientiﬁc research ﬁelds and the epistemic
politics of health social movements." Pp. 17-30 in Social Movements in Health,
edited by P. Brown and S. Zavestoski. Malden, MA: Blackwell Publishing.

Institute, National Cancer. 2009, "Reminder Card: Every Woman Should Know About

These 2 Tests", Retrieved June 12, 2009,
(http://www.cancer.gov/cancertopics/every-woman-should-know-about-these-2-
tests).

Johnson, Johnson &. 2009, "The Mammotome Biopsy System ", Retrieved May 15,
2009, (http://www.ethiconendo.com/dtcf/pages/breast_care.htrn).

J ournalStar. 1999, "Nancy Brinker: She's racing toward a cure", Retrieved June 7, 2009,
(http://www2.pj star.com/index.php/legacy/article/nancy_brinker_shes_racing_to
ward_a_cure/).

Keck, Margaret E. and Kathryn Sikkink. 1998. Activists Beyond Borders: Advocacy
Networks in International Politics. Ithaca: Cornell University Press.

Khagram, Sanjeev, James V. Riker, and Kathryn Sikkink. 2002. "From Santiago to
Seattle: Transnational Advocacy Groups Restructuring World Politics." Pp. 3-23
in Restructuring World Politics: Transnational Social Movements, Networks and

259

Norms, edited by S. Khagram, J. V. Riker, and K. Sikkink. Minneapolis:
University of Minnesota Press.

King, Samantha. 2006a. Pink Ribbons, Inc. : Breast Cancer and the Politics of
Philanthropy. Minneapolis: University of Minnesota Press.

—. 2006b. Pink Ribbons, Inc: Breast Cancer and the Politics of Philanthropy.
Minnesota: University of Minnesota Press.

Klawiter, Maren. 2000. "F rom Private Stigma to Global Assembly: Transforming the
Terrain of Breast Cancer." Pp. 299-334 in Global Ethnography: Forces,
Connections and Imaginations in a Postmodern World, edited by M. Burawoy, J.
A. Blum, S. George, and Z. Gille. Berkeley: University of California Press.

—. 2002. "Risk, Prevention and the Breast Cancer Continuum: The NCI, the FDA,
Health Activism and the Pharmaceutical Industry." History and Technology
18:309-353.

—. 2005. "Breast Cancer in Two Regimes: The Impact of Social Movements on Illness
Experience." Pp. 161-189 in Social Movements in Health, edited by P. Brown and
S. Zavestoski. Malden, MA: Blackwell Publishing.

—. 2008. The Biopolitics of Breast Cancer: Changing Cultures of Disease and Activism.
Minneapolis: University of Minnesota Press.

Kolker, Emily K. 2005. "Framing as a Cultural Resource in Health Social Movements:
Funding Activism and the Breast Cancer Movement in the US 1990-1993." Pp.
137-160 in Social Movements in Health, edited by P. Brown and S. Zavestoski.
Malden, MA: Blackwell Publishing.

Kriesberg, Louis. 1997. "Social Movements and Global Transformation." Pp. 3-18 in
Transnational Social Movements and Global Politics: Solidarity beyond the State,
edited by J. Smith, C. Chatﬁeld, and R. Pagnucco. Syracuse: Syracuse University.

Krimsky, Sheldon. 2000. "Environmental Endocrine Hypothesis and Public Policy." Pp.
95-107 in Illness and the Environment: A Reader in Contested Medicine, edited
by P. Brown, S. KroIl-Smith, and V. J. Gunter. New York: New York University
Press.

Kroll-Smith, Steve and H. Hugh Floyd. 1997. Bodies in Protest: Environmental Illness
and the Struggle over Medical Knowledge. New York: New York University
Press.

Lantz, Paula M. and Karen M. Booth. 1998. "The Social Construction of the Breast
Cancer Epidemic." Social Science & Medicine 46:907-918.

Lapp, Michael. 1995. "The Rise and Fall of Puerto Rico as a Social Laboratory, 1945-
1965." Social Science History 19: 169-199.

260

 

 

Lerner, Barron H. 2003. Breast Cancer Wars: Hope, Fear and the Pursuit of a Cure in
Twentieth Century America. Oxford: Oxford University Press.

Leysen, Betina. 1996. "Medicalization of Menopause: From 'Feminine F orever' to
'Healthy Forever'." Pp. 173-191 in Between Monsters, Goddesses and Cyborgs:
Feminist Confrontations with Science, Medicine and Cyberspace, edited by N.
Lykke and R. Braidotti. London: Zed Books.

Lorber, Judith. 1997. Gender and the Social Construction of Illness. London: Sage.

Love, Susan M, MD. and Karen Lindsey. 1997. "The Politics of Breast Cancer." Pp.
384-391 in Feminist Frontiers, vol. IV, edited by L. Richardson, V. Taylor, and
N. Whittier. New York: McGraw-Hill Companies, Inc.

Maugh, Thomas H. and Mary Engel. 2008. "Report to Congress: Gulf War Syndrome is
Real." in Los Angeles Times. Los Angeles.

Maxwell, J .A. 1998. "Designing a Qualitative Study." Pp. 69-100 in Handbook of
Applied Social Research Methods, edited by L. Bickman and D. J. Rog. Thousand
Oaks, CA: Sage.

McCarthy, John D. 1997. "The Globalization of Social Movement Theory." Pp. 243-259
in Transnational Social Movements and Global Politics: Solidarity Beyond the
State, edited by J. Smith, C. Chatﬁeld, and R. Pagnucco. Syracuse: Syracuse
University Press.

McCarthy, John D. and Meyer Zald. 1977. "Resource Mobilization and Social
Movements: A Partial Theory." American Journal of Sociology 82:1212-1241.

McCormick, Sabrina and Lori Baralt. 2006a. "'Corporatized Activism’: Blurring the
Boundaries between Corporations and Social Movements " in Society for the
Study of Social Problems Annual Meeting. Philadelphia, PA.

—. 2006b. “'Corporatized Activism’: Blurring the Boundaries between Corporations and
Social Movements ”.

McCormick, Sabrina, Julia Brody, Phil Brown, and Ruth Polk. 2004. "Public
Involvement in Breast Cancer Research: An Analysis and Model for Future
Research." International Journal of Health Services 34:625-646.

McCormick, Sabrina, Phil Brown, and Stephen Zavestoski. 2003. "The Personal is
Scientiﬁc, the Scientiﬁc is Political: The Public Paradigm of the Environmental
Breast Cancer Movement." S0ciological Forum 18:545-576.

Moffett, J. 2003. "Moving beyond the Pink Ribbon: An Examination of Breast Cancer
Advocacy and Activism in the US. and Canada." Cultural Dynamics 15:287-306.

261

Moghadam, Valentine M. 2001. "Transnational Feminist Networks: Collective Action in
an Era of Globalization." Pp. 111-139 in Globalization and Social Movements,
edited by P. Hamel, H. Lustiger-Thaler, J. N. Pieterse, and S. Rosenail. New
York: Pal grave.

Morris, Aldon. 2000. "Reﬂections on Social Movement Theory: Criticism and
Proposals." Contemporary Sociology 29:445-454.

Novartis, Oncology. 2009, "Novartis Oncology Products", Retrieved May 15, 2009,
(http://www.novartisoncology.com/novartis-oncology-products/index.jsp).

Olesen, Thomas and James N. Rosenau. 2005. “The Reduction of Distance and the
Construction of Proximity: Solidarity Movements and Globalization.” Paper
Presented at the Annual Meeting of the lntemational Studies Association,
Honolulu.

Olson, James S. 2005. Bathsheba's Breast: Women, Cancer, and History. Baltimore: The
Johns Hopkins University Press.

Organization, Pan American Health. 2007. "Health in the Americas, 2007, Volume 11-
Countries." Pan American Health Organization.

Organization, World Health. 2008, "The World Health Report 2008: Primary Health Care
Now More Than Ever", Retrieved May 15, 2009,
(http://www.who.int/whr/2008/en/index.html).

Parkin, D.M., F .I. Bray, and SS. Devesa. 2000. "Cancer Burden in the year 2000. The
global picture " European Journal of Cancer 37:S4-S66.

Parkin, D.M., F .I. Bray, J. F erlay, and Paola Pisani. 2005. "Global Cancer Statistics,
2002." CA: A Cancer Journal for Clinicians 55:74-108.

Parkin, D.M. and Leticia M.G. Fernandez. 2006. "Use of Statistics to Assess the Global
Burden of Breast Cancer." The Breast Journal 12:870-880.

Peterson, Melody. 2008. Our Daily Meds: How the Pharmaceutical Companies
Transformed Themselves into Slick Marketing Machines and Hooked the Nation
on Prescription Drugs. New York: Sarah Crichton Books.

Phillips, K.A., G. Glendon, and J .A. Knight. 1999. "Putting the Risk of Breast Cancer in
Perspective." The New England Journal of Medicine 340: 1-14.

Pieterse, Jan Nederveen. 2001. "Globalization and Collective Action." Pp. 21-39 in
Globalization and Social Movements, edited by J. N. Pieterse, H. Lustiger-Thaler,
P. Hamel, and S. Rosenail. New York: Palgrave.

Pringle, Hamish and Marjorie Thompson. 1999a. Brand Spirit: How Cause-Related
Marketing Builds Brands. New York Wiley.

262

 

—. 1999b. Brand Spirit: How Cause Related Marketing Builds Brands. New York:
Wiley

Reitan, Ruth. 2007. Global Activism, Edited by B. K. Gills. London: Routledge.

Reuters. 2008, "Susan G. Komen for the Cure's CEO HaIa Moddelmog Earns 'High Heels
in High Places'", Retrieved June 7, 2009,
(http://www.reuters.com/article/pressReIease/idUS61 026+] 2-Jan-

2008+PRN200801 12).

Rico, Government of Puerto. 2005, "Programa: Reforma de Salud", Retrieved June 12,
2009,
(http://www.presupuesto.gobierno.pr/PresupuestosAnteriores/af99/multiage/tarsal
ud.htm).

Rios Santiago, Carmelo J. 2006. "Reconocimiento del Senado de Puerto Rico a Maria A.
Benitez por su destacada labor en la lucha contra el cancer del seno en Puerto
Rico." San Juan, PR: Puerto Rican Senate.

Rosenbaum, Marcy E. and Gun M. Roos. 2000. "Women's Experiences of Breast
Cancer." Pp. 153-182 in Breast Cancer: Society Shapes an Epidemic, edited by A.
S. Kasper and S. J. Ferguson. New York: St. Martin's Press.

Rosser, Sue V. 2000. "Controversies in Breast Cancer Research." Pp. 245-271 in Breast
Cancer: Society Shapes an Epidemic, edited by A. S. Kasper and S. J. Ferguson.
New York: St. Martin's Press.

Ruzek, Sheryl Bert. 1999. "Rethinking Feminist Ideologies and Actions: Thoughts on the
Past and Future of Health Reform." Pp. 303-323 in Revisioning Women, Health

and Healing: Feminist, Cultural and T echnoscience Perspectives, edited by A. E.
Clarke and V. L. Olesen. New York: Routledge.

Ruzek, Sheryl Bert, Adele E. Clarke, and Virginia L. Olesen. 1999. "Social, Biomedical,
and Feminist Models of Women's Health." Pp. 11-28 in Women 's Health:
Complexities and Diﬂerences, edited by S. B. Ruzek, A. E. Clarke, and V. L.
Olesen. Columbus: Ohio State University Press.

Schwartzmann, Gilberto. 2001. "Breast Cancer in South America: Challenges to Improve
Early Detection and Medical Management of a Public Health Problem." Journal
of Clinical Oncology 19:1 188-1248.

SGKC. 2006a, "First Lady, Headed to Torino's Winter Olympics, Stops in Rome to Meet
Komen Italia Champions", Retrieved December 15, 2007,
(http://ww5 .komen.org/uploadedFiles/Content_Binaries/2004-
2005annualreport.pdf).

263

 

—. 2006b, "A Promise in Action: 2004-2005 Annual Report", Retrieved May 15, 2009,
(http://ww5.komen.org/uploadedFiles/Content_Binaries/2004-
2005annualreport.pdf).

—. 2006c, "The Susan G. Komen Breast Cancer Foundation joins US Department of
State to Launch Groundbreaking Breast Cancer Partnership in Middle East",
Retrieved December 15, 2007,
(http://ww5.komen.org/KomenNewsArticle.aspx?id=7680).

—. 2006d, "The Susan G. Komen Foundation Provides Another $3 Million for Global
Projects Impacting Disparities", Retrieved December 15, 2007,
(http://ww5.komen.org/KomenNewsArticle.aspx?id=7756).

—. 2007a, "Advocates Bring Community Perspective to Global Summit on Breast
Cancer", Retrieved January 15, 2008,
(http://ww5 .komen.org/KomenNewsArticle.aspx?id=75 14).

—. 2007b, "Brazil Launches Partnership for Breast Cancer Awareness and Research of
the Americas", Retrieved January 15, 2008,
(http://ww5.komen.org/KomenNewsArticle.aspx?id=7496).

—. 2007c, "Historic Breast Cancer Global Summit Opens in Budapest", Retrieved
January 15, 2008, (http://ww5.komen.org/KomenNewsArticle.aspx?id=7516).

—. 2007d, "Komen Launches New Brand for 25th Anniversary ", Retrieved June 7,
2009, (http://atlanta.daybooknetworjlgcom/story/Z007/01/22/2660komen-new-
brand.shtml

).

—. 2007c, "National Leadership in the Global Breast Cancer Movement Earns Award for
Founder of Susan G. Komen for the Cure", Retrieved January 15, 2008,
(http://ww5.komen.org/KomenNewsArticle.aspx?id=7626).

—-. 2007f, "Saudi Arabia Launch of U.S.-Middle East Partnership for Breast Cancer
Awareness and Research", Retrieved January 15, 2008,
(http://ww5.komen.org/KomenNewsArticle.aspx?id=7500).

—. 2007g, "Susan G. Komen for the Cure Announces Delegates for Historic Global
Advocate Summit", Retrieved January 15, 2008,
(httpz/lww5.komen.org/KomenNewsArticle.aspx?id=7558).

—. 2007h, "Susan G. Komen for the Cure Announces Extension of US-Middle East
Partnership for Breast Cancer Awareness and Research", Retrieved January 15,
2008, (http://ww5.komen.org/KomenNewsArticle.aspx?id=7620).

—. 2007i, "Susan G. Komen for the Cure Announces Historic Global Breast Cancer
Advocate Summit, Calls for Delegate Applications", Retrieved December 15,
2007, (http://ww5.komen.org/KomenNewsArticle.aspx?id=7642).

264

—. 2007j, "Susan G. Komen for the Cure Launches Unprecedented Global Expansion
Program in 10 Countries", Retrieved January 15, 2008,
Gittpz//ww5 .komen.org/KomenN ewsArticle.aspx?id=7 5 1 8).

—. 2007k, "Susan G. Komen for the Cure Partners with US State Department and MD.
Anderson to Ignite Breast Cancer Awareness and Research in Latin America",
Retrieved January 15, 2008,
(http://ww5.komen.org/KomenNewsArticle.aspx?id=7556).

—. 20071, "US-Middle East Partnership for Breast Cancer Awareness and Research-A
word from Nancy Brinker", Retrieved January 15, 2008,
(http://ww5.komen.org/KomenNewsArticle.aspx?id=7500).

—. 2008a, "Ambassador Nancy G. Brinker Included in TIME Magazine's "100 Most
Inﬂuential People" for 2008", Retrieved November 15, 2008,
(http://ww5.komen.org/KomenNewsArticIe.aspx?id=7442).

—. 2008b, "Gabrielle Union Helps Fight Breast Cancer in Ghana", Retrieved November
1 5, 2008, (http://ww5.komen.org/KomenNewsArticle.aspx?id=15712).

—. 20080, "Hundreds Turn Out in Dar es Salaam for Tanzania Race for the Cure",
Retrieved November 15, 2008,
(http://ww5 .komen.org/KomenNewsArticle.aspx?id=I 5 370).

—. 2008d, "Leading US Cancer Organizations Unite Against the Global Cancer Burden",
Retrieved November 15, 2008,
(http://ww5 .komen.org/KomenNewsArticle.aspx?id=1 5702).

—. 2008c, "Susan G. Komen for the Cure Announces Global Promise Fund to Help
Women Worldwide", Retrieved November 15, 2008,
(http://ww5.komen.org/KomenNewsArticle.aspx?id=7456).

—. 2008f, "Susan G. Komen for the Cure Founder Comments on Mumbai Attacks",
Retrieved January 15, 2009,
(http://ww5 .komen.org/KomenNewsArticle.aspx?id=1 5646).

—. 2008g, "Susan G. Komen for the Cure Sharing Grassroots Advocacy Knowledge with
International Representatives in Intensive Dallas Training Session", Retrieved
February 15, 2008, (http://ww5.komen.org/KomenNewsArticle.aspx?id=7466).

—. 2008h, "Susan G. Komen for the Cure, Mrs. Laura Bush Welcome Panama to
Partnership for Breast Cancer Awareness", Retrieved January 15, 2009,
(http://ww5 .komen.org/KomenNewsArticle.aspx?id=l 563 8).

—. 2008i, "Susan G. Komen for the Cure: 2008 Annual Report", Retrieved May 20,
2009, (http://ww5.komen.org/uploadedFiles/Content_Binaries/2008annual-
hr.pdf).

265

—. 2008j, "United State Embassy Joins with Susan G. Komen for the Cure and the
Cancer Society of the Bahamas for Historic Race in Supprot of Breast Cancer
Awareness", Retrieved December 15, 2008,

(http://ww5 .komen.org/KomenNewsArticle.aspx?id=1 5568).

—. 2009a, "Advisory Councils", Retrieved May 15, 2009,
(http://ww5.komen.org/aboutus/advisorycouncils.htrnl).

—. 2009b, "Board of Directors", Retrieved May 15, 2009,
(http://ww5.komen.org/AboutUs/BoardofDirectors.html).

—. 2009c, "Find a Komen Afﬁliate", Retrieved May 15, 2009,
(http://ww5.komen.org/afﬁliates.aspx).

-—. 2009d, "The Global Initiative on the Ground: Costa Rica", Retrieved February 15,
2009, (http://www.globalkomen.org/country/country_costarica.htm).

—. 2009c, "Million Dollar Council Elite", Retrieved June 4, 2009,
(http://ww5.komen.org/milliondollarcouncil.aspx).

—. 2009f, "Nancy G. Brinker", Retrieved June 1, 2009,
(http://ww5.komen.org/AboutUs/NancyBrinker.html).

—. 2009g, "Scientiﬁc Advisory Board", Retrieved May 15, 2009,
(http://ww5.komen.org/AboutUs/ScientiﬁcAdvisoryBoard.html).

Sikkink, Kathryn and Jackie Smith. 2002. "Infrastructures for Change: Transnational
Organizations, 1953-93." Pp. 24-46 in Restructuring World Politics:

Transnational Social Movements, Networks and Norms, edited by S. Khagram, J.
V. Riker, and K. Sikkink. New York: Palgrave.

Simpson, Christy. 2000. "Controversies in Breast Cancer Prevention: The Discourse of
Risk." Pp. 131-152 in Ideologies of Breast Cancer: Feminist Perspectives, edited
by L. Potts. New York: St. Martin's Press.

Smith, Jackie. 2004. "Transnational Processes and Movements." Pp. 311-336 in The
Blackwell Companion to Social Movements, edited by D. A. Snow, S. A. Soule,
and H. Kriesi: Blackwell Publishing.

Smith, Jackie, Ron Pagnucco, and Charles Chatﬁeld. 1997. "Social Movements and
World Politics: A theoretical Framework." Pp. 59-80 in Transnational Social
Movements and Global Politics: Solidarity beyond the State, edited by J. Smith,
C. Chatﬁeld, and R. Pagnucco. Syracuse: Syracuse University Press.

Snow, David A. , Sarah A. Soule, and Hanspeter Kriesi. 2004. "Mapping the Terrain."
Pp. 3-16 in The Blackwell Companion to Social Movements, edited by D. A.
Snow, S. A. Soule, and H. Kriesi. Oxford: Blackwell Publishers.

266

Sontag, Susan. 1989. Illness as Metaphor and AIDS and Its Metaphors. New York: St.
Martin's Press.

Stabiner, J. 1997. T 0 Dance with the Devil: The New War on Breast Cancer. New York
Delacourt Press.

Steingraber, Sandra. 2000. "The Environmental Link to Breast Cancer." Pp. 271-302 in
Breast Cancer: Society Shapes an Epidemic, edited by A. S. Kasper and S. J.
Ferguson. New York: St. Martin's Press.

Strauss, Anselm and Juliet Corbin. 1998. Basics of Qualitative Research. Thousand
Oaks: Sage Publications, Inc.

Tarrow, Sidney. 1998. Power in Movement: Social Movements and Contentious Politics.
New York: Cambridge University Press.

—. 2005. The New Transnational Activism. Cambridge: Cambridge University Press.

Times, New York. 1992, "A Heaping Plate of Ventures for Chili's Impresario" The New
York Times, (http://www.nytimes.com/1992/08/29/business/a-heaping-plate-of-
ventures-for-chili-s-impresario.htrnl?sec=&spon=&pagewanted=all).

Trombley, Stephen. 1988. The Right to Reproduce: A History of Coercive Sterilization.
London: Weidendfeld & Nicolson.

Van Dyke, Nella, Sarah A. Soule, and Verta Taylor. 2004. "The Targets of Social
Movements: Beyond a Focus on the State." Research in Social Movements,
Conﬂicts and Change 25 :27-5 1.

Wade, Nicholas. 2007. "Genome Researchers Find New Indicators of Breast Cancer
Risk." in New York Times. New York.

Weisman, Carol S. 2000. "Breast Cancer Policymaking." Pp. 213-244 in Breast Cancer:
Society Shapes an Epidemic, edited by A. S. Kasper and S. J. Ferguson. New
York: St. Martin's Press.

Westfall, Rachel Emma and Cecilia Benoit. 2004. "The Rhetoric of "Natural" in Natural
Childbirth: Childbearing Women's Perspectives on Prolonged Pregnancy and
Induction of Labour." Social Science & Medicine 59:1397-1408.

WHO. 2008a, "The World Health Report 2008: Primary Health Care Now More Than
Ever", Retrieved May 15, 2009, (http://www.who.int/whr/2008/en/index.html).

—. 2008b, "World Health Statistics 2008", Retrieved January 20, 2009,
(http://www.who.int/whosis/whostat/EN_WHSOS_Full.pdf).

—. 2009, "What is the WHO deﬁnition of health?", Retrieved May 30, 2009,
(http://www.who.int/suggestions/faq/en/index.htrnl).

267

 

WomensBiz. 2005, "Women to Watch", Retrieved June 7, 2009,
(http://womensbiz.us/images/issueart/w2wjuneOS.pdf).

Yaziji, Michael and Jonathan Doh. 2009. NGOs and Corporations: Conﬂict and
Collaboration. New York: Cambridge University Press.

Zavestoski, Stephen, Phil Brown, and Sabrina McCormick. 2004. "Gender, Embodiment
and Disease: Environmental Breast Cancer Activists' Challenges to Science, the
Biomedical Model, and Policy." Science as Culture 13:563-586.

Zones, Jane S. 2000. “Proﬁts from Pain: The Political Economy of Breast Cancer.” Pp.
119-152 in Breast Cancer: Society Shapes an Epidemic, edited by A. S. Kasper
and S. J. Ferguson. New York: St. Martin’s Press.

Zoomlnfo. 2008, “Ms. Susan Braun”, Retrieved June 4, 2009,
(http://www.zoominfo.com/people/Braun_Susan_1 235 1 24.aspx).

268

 

 

 

90

111111[111,11u11111111111111