By Mireille Aylwin (Contributor)
As a general practitioner in Canada I have, on many occasions, witnessed patients making decisions that are seemingly inconsistent with their preferences. For example, Tom[1], a patient I was treating for various chronic conditions once came to a follow-up appointment and explicitly requested at the very start of the interview that he not be prescribed more drugs. He believed he was already taking enough pills to control his hypertension and diabetes. However, when discussing his newly discovered high cholesterol (which could have had serious implications on his health considering his risk factors) he refused to go through a free nutrition and exercises program and chose instead to be prescribed anti-cholesterol medication. This decision came as a surprise to me as the proposed non-pharmaceutical approach was both consistent with the patient’s expressed wishes, with cholesterol lowering clinical guidelines, and with compliance research showing that patients with chronic diseases wish to avoid taking medication[2]. I will argue here that Tom’s seemingly irrational course of action partially stemmed from the pharmaceuticalisation[3] of health, a process which supports the assumption that a ‘magic pill’ can effectively treat or control any social, behavioural or bodily conditions. Herein I explore the contribution of patients, doctors and pharmaceutical companies to such pharmaceuticalisation of health, while keeping in mind that other actors such as governments and professional institutions are also involved.
When it comes to medical decisions, ‘rationality’ is often perceived as being in line with the objective scientific reality of diseases which are ‘biological, universal, and ultimately transcend[s] social and cultural context [4].’ Medical anthropology serves to bridge the gap between this simplistic notion of rational decision-making based on ‘knowledge’ and that of apparently irrational decision-making based on ‘beliefs.’ Health decision-making often confronts the difficult choice between lifestyle changes demanding hard work and self-control, and procrastination, or alternate options such as medication taking[5]. While a critical observer may consider that choices maintaining unhealthy habits is a reflection of laziness, the issue is much more complex as these condemned habits have a purpose in the balanced life of individuals[6]. As Laurent Berland puts it: ‘eating provides a kind of rest for the exhausted self, an interruption of being good, conscious and intentional that feels like a relief[7].’ The same could be said of smoking or watching television. Changing deeply rooted habits can be difficult, not only because of the motivation it demands, but also because it challenges one’s very identity as daily practices reflect ones’ preferences and desires, and are influenced, amongst other things, by social class, income and education.
Moreover, preventative medicine based on calculation of risk has defined new types of illnesses such as hypertension, diabetes, cholesterol that cause little or no symptoms. Individuals are transformed into patients based on abnormal laboratory or blood pressure measure and are recommenced long-lasting life-style changes or drug taking while they actually feel great. In such a setting, compliance can only be suboptimal because the benefit of a daily action resides in an abstract uncertain future, described in terms of the probability of bad outcomes 20 years henceforth, which are difficult to grasp for the asymptomatic patient. Some have observed that in order to achieve compliance, a patient must differentiate himself from his illness in order to accept it and successfully treat it[8]. Such separation is not simple whichever new diagnosis a patient is receiving, but imagine how hard it is when the identified condition is embodied by the patient, such as obesity, compared with illnesses caused by outside invaders such as infectious diseases or even cancerous growth… The very terms used regarding obesity reflect this struggle: one tends to say that someone ‘is’ obese rather then ‘has’ obesity. The complex struggle over identity and responsibility experienced by a patient who are confronted with a new diagnostic and its treatment options are, I believe, partly responsible for the pharmaceuticalisation of health and the compliance difficulties observed in chronic illnesses.
Doctors also contribute to the construction of the ‘magic pill’ in various complex ways. For example, workload and time pressure in certain clinical settings can lead to over-prescribing in order to avoid time-consuming confrontation[9] with a patient requesting a specific medication (i.e. antibiotics for a common cold) or to avoid having to admit that nothing can be done for a specific clinical situation, which can be experienced as a failure for certain physicians. Furthermore, doctor’s training is focused on drug prescriptions, which shapes the professional mind-sets about the central place of pills in the treatment of many afflictions. The sheer volume of medication on the market, and of new scientific data combined with physician’s time constraints and inconsistent critical reading abilities[10][11] adds to the difficulty of being up to date on the best current treatment. Physicians may compensate by over-reliance on easy but potentially biased sources of information such as media or pharmaceutical representatives or follow practices which are not part of current-guidelines, thus contributing to inadequate drug prescriptions. Many more factors involving doctors certainly contribute to the pharmaceuticalisation of health amongst which the relationship with pharmaceutical companies is clearly problematic.
The question of the construction of the ‘magic pill’ becomes most interesting when looking at pharmaceutical companies. It is no secret that pharmaceutical companies are some of the most lucrative companies in the world, or that they excel in manipulating information to make profit. A massive chunk of their budget is dedicated to marketing targeted to professionals, or directly to consumer in countries such as the US and New Zealand. Doctors are showered with branded material (pen, prescription pad, bags, posters…), informational pamphlets, free drug samples, and free lunches or conferences under the pretence of continuous education from the early stages of medical training. Patients are exposed to commercials carrying stereotypical social images of diseases, designed so they recognize themselves or their loved ones within them and request a specific medication from their doctors, who are then more likely to prescribe it to avoid confrontation or because of a fear of legal action[12]. While all of these techniques have an obvious impact on drug-prescription, it is only the tip of the iceberg.
Pharmaceutical companies are also involved in the production of scientific data through the financing of well-chosen research projects which find new indications for specific drugs or indirectly help promote off-label indications. By strategically choosing the areas in which they invest their research money, pharmaceutical companies disproportionally give more exposure and attention to some illnesses over others. Problems affecting larger proportion of population, and thus possessing a higher potential to general profit are therefore favoured in research budgets. Another strategy, known as ghost-writing involves the very production of scientific articles by public relations firms. Pfizer was involved in such as scam and ghost-written publications about Zoloft were tracked down from 1998-2000[13]. Those publications were not only found in greater quantity than traditionally authored publications, but were also published in more prestigious journals, relayed more positive data on Zoloft, and were cited more often in other scientific publications. It is very difficult to evaluate the extent to which this practice is used, but entire ghost-written scientific journals have been discovered.
Furthermore, pharmaceutical corporations are now involved in the creation of disease definitions and the pharmaceuticalisation of ordinary life, a process Moynihan defined as ‘disease mongering’[14]. The rebranding of Prozac as Serafem by Eli Lilly is an example of such influence [15]. The company was directly involved in the lobbying that led to the official recognition of “premenstrual dysphoric disorder” and its inclusion in the Diagnostic and Statistical Manual of Mental Disorders. The official recognition of premenstrual disorder allowed the company to rebrand and re-patent the anti-depressant Prozac under the name Serafem, the exact same molecule but coloured purple and with the specific indication to treat this new syndrome. The fact that this coincided with the expiration of the patent of the lucrative Prozac makes me as uncomfortable as the fact that the marketing of Serafem promotes the notion that symptoms related to a woman’s hormonal cycle are abnormal.
Moynihan also described how certain pharmaceutical companies are involved on the one hand in forums aiming at defining an official diagnostic for female sexual dysfunction, while on the other hand funding research to explore the effects of Viagra on female sexual response[16]. This approach makes sense from a business perspective, as both an official diagnostic and a drug proved effective are necessary to create a pharmaceutical business success[17]. However this meddling in the definition of female sexual dysfunction risks changing the conception of female sexuality by promoting the abnormality of normal sexual variations, such as the one secondary to tiredness, conflicts, or hormone cycle. This reality is well summarised by Moynihan, who says that ‘the potential risk, in a process so heavily sponsored by drug companies, is that the complex social, personal, and physical causes of sexual difficulties—and the range of solutions to them—will be swept away in the rush to diagnose, label, and prescribe[18]’. The emphasis on dysfunction and diagnostic production creates a larger amount of people potentially inclined to purchase medication to treat not only sexual dysfunction but anything from normal life changes such as baldness to social problems such as social phobia and attention deficit disorder.
In a time when nearly all information concerning health emanating from North America is associated with some form of drug advertising, it is no surprise that the assumption that a ‘magic pill’ can treat any kind of ailment is elevated to the ground of rational knowledge and expectation for both patients and doctors. However, this paradigm of health is based, as we have seen, on manipulated data raising questions that remain to be answered about the prized evidence-based medicine that rule biomedical practice.
Mireille Aylwin is a physician from Quebec, who recently graduated from the University of Edinburgh with a Masters in Medical Anthropology. You can read more of Mireille's articles here.
[1] Fictitious name
[2] Pound, P., Britten, N., Morgan, M., Yardley, L., Pope, C., Daker-White, G. and Campbell, R. (2005) Resisting Medicines: a Synthesis of Qualitative Studies of Medicine Taking. Social Science & Medicine. 61: 133–155.
[3] Abraham, J. (2009) The pharmaceutical industry, the state and the NHS. In J. Gabe and M. Calnan The New Society of the Health Service. New York: Routledge.
[4] Good, B.J. (1994) Medicine, rationality, and experience: An anthropological perspective. Cambridge: Cambridge University Press. (p.8)
[5] Ariely, D. (2010) Predictably Irrational: The Hidden Forces that Shape our Decisions. New York: Harper Perennial.
[6] Metzl, J. (2010) Introduction: Why ‘Against Health’? in J. Metzl and A. Kirkland (eds.) Against Health: How Health Became the New Morality. New York: New York University Press.
[7] Berland, L. (2010) Risky Business: On Obesity, Eating, and the Ambiguity of ‘Health’. in J. Metzl and A. Kirkland (eds.) Against Health: How Health Became the New Morality. New York: New York University Press. (p.26)
[8] Aujoulat, I. Marcolongo, R., Bonadiman, L. and Deccache, A. (2003) Reconsidering Patient Empowerment in Chronic Illness: A Critique of Models of Self-efficacy and Bodily Control. Social Science & Medicine 66: 1228-1239.
[9] Kenealy, T. and Arroll, B. (2013) Antibiotics for the common cold and acute purulent rhinitis. [Systematic Review] Cochrane Database of Systematic Reviews. [Online]. Available at : http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000247.pub3/abstract. [Accessed 19 August 2014].
[10] Oliveri, R.S., Gluud, C. and Wille-Jorgensen, P.A. (2004) Hospital doctors’ self-rated skills in and use of evidence-based medicine – a questionnaire survey. Journal of Evaluation in Clinical Practice 10 (2): 219-226.
[11] Young, J.M., Glasziou, P. and Ward, J.E. (2002) General practitioners' self ratings of skills in evidence based medicine: validation study. BMJ 324:950–951.
[12] Metzl, J. (2007) If Direct-to-Consumer Advertisements Come to Europe: Lessons from the USA. Lancet 369: 704–06.
[13] Elliot, C. (2010) Pharmaceutical Propaganda. in J. Metzl and A. Kirkland (eds.) Against Health: How Health Became the New Morality. New York: New York University Press.
[14] Moynihan, R., Heath I. and Henry D. (2002) Selling Sickness: the Pharmaceutical Industry and Disease Mongering. BJM 324: 886-891.
[15] Greenslit, N. (2006) Dep®ession and Consum$tion: Psychopharmaceuticals, Branding, and New Identity Practices. Culture, Medicine, and Psychiatry 30(1): 477-501.
[16] Moynihan, R. (2003) The Making of a Disease: Female Sexual Dysfunction. BJM 326: 45-47.
[17] Tiefer, L. (2000) Sexology and the Pharmaceutical Industry : The Threat of Co-optation. The Journal of Sex Research 37(3) : 273-283.
[18] Moynihan, R. (2003) The Making of a Disease: Female Sexual Dysfunction. BJM 326: 45-47. (p.27)