An attractive young woman glances to one side and touches her tongue to her upper lip. She looks as though she's just heard a dirty joke. An arrow points to an almost imperceptible white speck on her tongue, and there is text beside it: "It's tiny now. Don't let it grow up to be oral cancer."
Five hundred of these public service announcements have been plastered up in New York City subway and commuter rail stations since the American Dental Association's 11-city campaign began here on Nov. 1. A second image shows a close-up of a lipsticked mouth projecting a photogenic tongue. There is another white speck, or is it a bit of glare? "See your dentist. Testing is now painless."
Never mind that one of these images is a stock photo, and that the white specks are added in post-production. That is of as little concern to the campaign designers as the fact that 90 percent of those diagnosed with oral cancer are over 45 years old, that most are men, that almost all either smoke or drink heavily and that African-Americans are at highest risk.
"You can argue that a 65-year-old, heavy smoker and drinker who looks down and out might more accurately have represented the target audience," said an ADA representative who chose to remain anonymous. "But would anyone have paid attention to that?"
It's possible that 65-year-olds would have paid a bit more attention. But they make up a small percentage of the people who will be viewing the ads. Everyone with a modicum of business sense knows that the best way to get a message out is to market to the middle. "The woman is young and attractive," continues the same ADA representative, "and we believe that's increased the campaign's visibility."
Exposure is the bottom line. "The overarching goal of the campaign is to get more people aware of oral cancer," explains Sandra Stahl, vice president of marketing for CDx Laboratories -- the corporation that funded the campaign with a public service grant. "Every effort was made to communicate as broadly as possible." In the linguistics of advertising, the young, attractive white woman on the poster is Esperanto.
Despite her mass appeal, the lip-smacking poster girl is not the target audience. Caucasian women already see their dentists 2.4 times per year, according to the Centers for Disease Control -- more often than any other group. And they're 30 percent more likely to have the insurance to pay for those visits than people of other races. Even if they've never heard of oral cancer -- and this is a crucial point for a public awareness campaign -- as regular dental patients they are probably being tested for the disease already. Dr. Lawrence H. Meskin, former editor of the Journal of the American Dental Association, has written on the many screenings that are performed unannounced in the course of regular check-ups.
It is no surprise that those who are at greatest risk for developing oral cancer -- older patients and African-Americans -- have the least access to a widespread (although covert) screening program that is already in place. The ADA has signed off on a campaign whose primary goal should be to rein in these outliers dying at the highest rate, but whose strategy rests on the familiar marketing logic of maximum visibility and targeting the center.
Why should we expect otherwise? No one involved in the campaign apologizes for the intertwining of private and public interests at its roots: The source of funding for the ads is also the developer and sole manufacturer of OralCDx, the noninvasive brush biopsy alluded to in the campaign slogan "testing is now painless." For every patient who undergoes an OralCDx biopsy, CDx Laboratories earns a $65 fee to process the results. And for every person who sees the ad and rushes to get screened, a private dentist charges a fee of about $95 for the checkup. In terms of revenue, it makes perfect sense to raise awareness among the people who are most likely to schedule an appointment. Again, these people are the least likely to die of oral cancer.
Concerns about the campaign are sloughed off as the niggling residue of corporate sponsorship. The potential health benefits of a well-funded marketing scheme can justify a great deal.
"It's better than nothing, that at least it becomes an issue," says Dr. Seymour Rettinger, a member of the ADA for the past 41 years. "We all understand that very few campaigns have people who are middle-aged."
The arrangement was negotiated by the ADA according to its well-defined partnerships policy, and despite the fact that OralCDx is the only biopsy or screening product to earn the ADA "seal of acceptance," no explicit mention of it is made in the most visible promotional material. But even the implied conflict of interest is enough to worry bioethicists.
"These ads are a classic example of what professional societies should not do," says Glenn McGee, the editor-in-chief of the American Journal of Bioethics. "No matter how well-intentioned, corporate sponsored campaigns on the part of the most important association in dentistry send the message that the organization is bought."
That message may be secondary if the campaign saves lives. In theory, the ads could reduce mortality by promoting screening, and thereby increasing the number of oral cancers that are detected at an early, more easily treatable stage. But the question of whether oral cancer screening does in fact reduce mortality rates remains unresolved, according to the National Cancer Institute; its answer would require further large-scale clinical study.
If it might save lives, it stands to reason, why not do it? This is the same argument that has been made in favor of continuing mammography in the face of controversial clinical data. But the same counter-arguments apply: Opponents of mammography point out that false positives are four to five times more likely than correct identifications, and potentially lead to hundreds of thousands of unnecessary and anxiety-provoking biopsies per year. According to the ADA's statistics, 10 percent of the population has questionable sores that might merit a biopsy, but less than .02 percent of the population gets oral cancer. In other words, 500 oral cancer biopsies are likely to turn up negative for every positive result.
"Clearly there's a tremendous amount of literature associated with false positives," says Dr. Lisa Lehmann of the Division of Medical Ethics at Harvard Medical School. "We tend to neglect the very serious psychological sequelae of taking the test."
To claim that the willful misrepresentation of risk is inconsequential compared to an increased awareness of oral cancer suggests a dangerous reinterpretation of "awareness" as an end in itself. The real value of awareness ought to be defined in terms of the social decision-making that emerges from it, and not from its marketability. The success of the ADA-CDx campaign -- that is, the degree to which it raises awareness -- depends on the number of people who get screened, whether or not those people are at risk.
More distressing is the possibility that a corporate-funded campaign of this kind gobbles up a finite resource by invading the public space. As consciousness-raising begins to rely on commercial strategies to underscore its message, it becomes more and more apparent that "awareness" is a commodity -- and a legitimate marketing target in its own right. By partnering with a professional society, a company like CDx can seize market share with concrete value and measurable returns.
Private funding can provide a conduit for important public health messages that would not otherwise be heard. But the professional and health organizations that validate these campaigns have a responsibility to guide the resources toward the areas of greatest need. The oral cancer campaign could have emphasized prevention over detection, and it could have targeted the people at the greatest risk for the disease. Neither of these strategies precludes corporate funding; Zila Pharmaceuticals is financing just such a campaign in the coming months. Obviously it would be foolish to restrict corporations to bald profiteering; as long as necessity directs their public service efforts, "awareness" can be invested responsibly and to the greatest benefit.