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Society's Choices: Social and Ethical Decision Making in Biomedicine
only because of weak governmental support for such research but also because of the willingness of NRLC and other antiabortion groups to engage in public protests and threaten boycotts if they do proceed with such research. The history of the development and distribution of RU486 in France confirms that these fears of reprisal are well founded. Because many drug companies are unwilling to become the target of controversial protests, they will avoid areas of research that may provoke such action. In the case of RU-486, and in the development of contraceptive technology in general, the grassroots antiabortion movement thus far has been largely successful in its goal (Charo, 1991).
Sometimes entire communities (whether geographic, ethnic, or cultural) respond to the changes brought about by technological advances. The response of communities has been variable: weaker for general health initiatives, but often stronger for specific initiatives such as screening for genetic disease. Success in the latter enterprise has also varied widely depending on the particular community and the strategies of the agencies that initiate and organize the screening. In general, however, large-scale community-based health education and intervention programs-in such areas as heart disease, nutrition, smoking, and drugs-have either not worked or worked only within certain limited class, educational, cultural, and racially or ethnically distinct community segments. Few have succeeded in effecting lasting changes in health behavior (Mechanic, 1990, 1992). Their failure is increasingly recognized as a function of treating health behavior as an individual rather than a social and cultural phenomenon (Mechanic, 1990; Syme and Alcalay, 1982). One notable exception is the recent series of efforts to curb smoking by stepping up public education and by banning smoking in public places; these initiatives seem to have reduced smoking behavior in many sectors of society. A growing body of research shows that cultural factors are critical to understanding and modifying health-related behavior, including preventive action (Cruickshank and Beevers, 1989; Graham, 1984; Mascie-Taylor, 1993; Strauss, 1991; Helman, 1990; Biersecker et al., 1987; Armstrong, 1989).
Assessing Genetic Risks
Cultural issues are particularly salient in understanding responses to new genetic knowledge and screening possibilities, in part because genetic disorders, to a greater extent than other health problems, coincide with "risk populations" that are ethnically and racially demarcated. Thus, each disorder may exist in a different cultural context: Americans of African