The Spaces of Screening: Tracing the Spatial Geographies of Mobile Mammography from Carparks to the Cosmos

Jennifer Fraser

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In 2019, Britain’s National Health Service (NHS) launched a new cancer detection initiative. In this pilot program, the NHS harnessed “technology developed for space travel” to design a series of mobile cancer screening vans, which have been placed in Sainsbury’s and Morrisons supermarket parking lots across Great Britain (Figure 1). Designed by the UK space agency, these supermarket screening facilities make use of 4G networks and direct satellite links to transport scans directly to hospital experts for analysis. Whereas in the past women had to make an appointment at their local mammography clinic and then wait weeks to find out their results, these new mobile labs allow women get screened more conveniently and then hear back from a medical professional in a matter of days.

The NHS is not the only organization that has turned to mobile mammography as a means of improving women’s access to cancer detection. Built into busses, trailers, trucks, and vans, mobile mammography units can be found in carparks, festivals, and county health clinics around the world. As a result of its ability to meet women where they are, mobile mammography is often framed as the solution to creating more comfortable, convenient and, above all, equitable screening practices. But are these mobile units the same as more fixed screening sites? Do they really provide the same uniform standard of care that is found in hospital screening rooms? Or does the site-specific and itinerant nature of mobile mammograms affect the way that screening is delivered? To find out if where you get your mammogram matters, this piece explores the “spaces of screening” — focusing particularly on the historical evolution of mobile mammography from the 1960s to the present day. While these units are often framed as neutral homogenous and ambulatory spaces, the following three examples will demonstrate how they are profoundly influenced by their settings and reflect prevailing ideas about the landscapes and communities they operate within.

Mammograms in the City: The History of Portable Screening in the USA

Mammography first started to be used as a tool for mass breast cancer screening in the late 1960s and early 1970s.¹ Although these imaging devices were often based in hospitals and cancer clinics, the diffusion of these technologies into clinical practice caused researchers to wonder about the benefits of developing more portable forms of screening. One early proponent of mobile mammography was the radiologist Philip Strax.² Concerned that traditional methods of screening were missing large swatches of the American population, in the late 1960s Strax decided to develop and operate a self-contained mobile unit that could be driven around New York City.³ He believed that this shift would overcome a lot of the barriers preventing women from accessing screening services, such as the inconvenient location of many breast cancer clinics, along with their limited operating hours.⁴

While Strax stated that his mobile unit was devised for the “average” American woman, a closer look at the bus’s logistics and layout reveals that he had very specific populations in mind when designing his new screening apparatus.⁵ Rather than targeting the Upper East Side, or other affluent New York City neighborhoods, from the late 1960s-1970s, Strax based his unit in low income communities, such as the prominent African-American and Latino enclaves of Central and East Harlem.⁶ His reason for targeting these neighborhoods was largely driven by preconceived notions about the health risks and practices of the women living there. Like many of his contemporaries, Strax believed that visible minorities and the urban poor were not only less motivated to seek medical care than women living in whiter, wealthier communities, but that they were also less likely to access the city’s stationary screening centers located in mid-Manhattan.⁷

To these ends, Strax adopted a number of strategies to “indoctrinate” these “reluctant” women to the point that they would not only “accept the examinations, but also to demand them.”⁸ For instance, he tried to overcome linguistic barriers by ensuring that all of the bus’s signage was bilingual (Figure 2). He also outfitted his unit with a corps of health care workers, who were responsible for informing community members about their risk of developing the disease as well as the importance of undergoing regular screening.⁹

Screening on the Geographic Periphery: Mobile Mammography in Canada

While mobile mammography units had circulated in the United States since the 1960s, they would not cross the border into Canada until the 1990s when officials from British Columbia’s Screening Mammography Program (SMP) purchased Canada’s first-ever mobile mammography vehicle (Figure 3).¹⁰ Much like Strax’s van, the SMP RV was also charged with the task of reaching groups that had evaded provincial screening programs.¹¹ In practice, this meant that the RV was largely directed toward Indigenous women living within the province’s sparsely populated interior, as these communities were thought to have low rates of screening participation and a poor record of health compliance.¹² As a result, in addition to expanding the RV’s itinerary so that it made more stops in Indigenous communities, the SMP RV also hosted a number of community events intended to attract First Nations women to make use of these newly available screening services.

However, providing women with information about and access to screening did not always translate into greater health outcomes or more equitable care. The realities of contending with inclement weather, harsh terrain, and heavy use meant that the SMP RV was often in a state of disrepair, with many technicians commenting that “haywire and duct tape” were the only things holding the unit together.¹³ Furthermore, even in cases where early detection was successful, there was no guarantee that a positive screen would translate into effective treatment. This is because many of the rural and remote communities being targeted by the unit had no local hospitals, meaning that women were required to travel long distances in order to receive cancer care, often at a great financial and emotional cost. While the SMP RV undoubtedly provided important services to isolated communities, its aims seem to have been, at times, more aligned with extending the BC government’s jurisdiction over First Nations health and health services than setting up a system of coordinated care.

Space and the Future of Cancer Screening

The NHS’s use of supermarket parking lots and space technology highlights the role of geography in the design, use, and uptake of breast cancer screening. Unlike Strax’s “mammomobile” or the SMP’s screening RV, the NHS units were not designed to target the urban poor, certain ethnic groups, or women from rural or remote communities. Rather, they were developed to meet the healthcare needs of moneyed career women, who in between work and home commitments, had trouble finding the time to schedule a scan. By comparing their units to the UK Space Agency, these NHS vans promise a particular kind of screening experience — one that points towards luxury, social status, and a future where getting a mammogram is as quick and painless as running to the grocery store to grab something for dinner.

Mobile cancer screening units both influence and are influenced by the settings in which they operate. They reflect the external world, and they actively produce it — transforming minibuses into sites of medical indoctrination, RVs into mechanisms of state-surveillance, and parking lots into portals to a breast-cancer free future. While space plays different roles and takes on different meanings in each of the case studies presented, it is clear that mobile mammography units are a geographical phenomenon. Space might not be the first thing that comes to mind when considering where to get your mammogram. However, it is clear that ideas about where you live and what kind of community you belong to will shape your screening experience. While this can, at times, improve health equity and pave the way for more locally-situated and sensitive forms of care, they can also transform screening facilities into sites of inequality by providing cutting-edge care for certain populations, while operating as agents of medical cooptation and control for others.

Notes

1. Handel Reynolds, The Big Squeeze: A Social and Political History of the Controversial Mammogram (Ithaca: Cornell University Press, 2012), 16. See also Barron H Lerner, The Breast Cancer Wars: Hope, Fear, and the Pursuit of a Cure in Twentieth Century America (Oxford: Oxford University Press, 2001). Return to text.
2. R. H. Gold, L. W. Bassett, B. E. Widoff, “Highlights from the history of mammography,” Radiographics 10, no. 6 (1990): 1118. See also, Eric Nagourney, “Dr Philip Strax, 90, is Dead; An Advocate of Mammograms,” New York Times, March 11, 1999. Return to text.
3. It should be noted that Strax’s Female Cancer Detection Mobile Unit emerged of the now infamous Health Insurance Plan of New York Breast Cancer Study, which was the first randomized controlled trial of periodic screening with physical examination and mammography to determine whether the technique was effective in reducing breast cancer mortality. Alan B Hollingsworth, Mammography and Early Breast Cancer Detection: How Screening Saves Lives (Jefferson, NC: McFarland & Company, 2016), 2. Return to text.
4. Philip Strax, “Female Cancer Detection Mobile Unit,” Preventative Medicine 1 (1972): 425. Return to text.
5. Philip Strax, “Female Cancer Detection Mobile Unit,” Preventative Medicine 1 (1972): 425. Return to text.
6. Philip Strax, “Strategy (Motivation) for Detection of Early Breast Cancer,” Cancer 15, no. 46 (1980): 929. Return to text.
7. For more on the history of race and cancer risk in mid-twentieth century America, see Keith Wailoo, How Cancer Crossed the Color Line (Oxford: Oxford University Press, 2011). Return to text.
8. Strax, “Strategy (Motivation) for Detection of Early Breast Cancer,” 927. Return to text.
9. Strax, “Strategy (Motivation) for Detection of Early Breast Cancer,” 927. Return to text.
10. Graham Clay, T. Gregory Hislop, Lisa Kan, Ivo A. Olivotto, and Linda J. Warren Burhenne, “Screening Mammography in British Columbia,” The American Journal of Surgery 159 (1990): 472. Return to text.
11. Graham Clay, T. Gregory Hislop, Lisa Kan, Ivo A. Olivotto, and Linda J. Warren Burhenne, “Screening Mammography in British Columbia,” The American Journal of Surgery 159 (1990): 472. Return to text.
12. Andy Ivens, “TV ads urge women to get mammograms,” The Province, March 29, 1996. Return to text.
13. Barb Brouwer, “Local site needed for mammography,” Salmon Arm Observer, July 21, 1999. Return to text.

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Featured image caption: The first SMP Mobile Mammography Vehicle. (Courtesy Celebrating 25 Years of Breast Screening in BC, Vancouver: BC Cancer Agency)