In the previous post, I described some of the ways in which demand for pharmaceuticals is stimulated: disease awareness campaigns and the exaggeration or misrepresentation of medical scientific evidence regarding the safety and efficacy of many drugs. These are wide-ranging influences. However, the most insidious campaign to expand pharmaceutical sales is the effort to capture for pharmaceuticals a greater share in public health budgets—which in most of the world outside the US represents the greatest source of pharmaceutical spending. The ability to supply drugs to the global body is contingent upon altering public health policies concerning the approval and reimbursement of patented drugs.
Drug companies see their products not as complementary to other forms of therapy, but in competition with them. Success is therefore defined relative to the industry’s ability to instill overconfidence in “magic bullet” solutions—meaning the use of pharmaceuticals and other high tech interventions—to cure most forms of illness. João Biehl and others refer to the results of this overconfidence as “pharmaceuticalization,” and I will adopt that term.
Pharmaceuticalization is promoted abroad by the lobbying efforts of PhRMA (Pharmaceutical Research and Manufacturers of America) and with the aid of industry-buoyed trade mechanisms such as the ICH (International Council on Harmonization). Pharmaceuticalization has already unleashed dubious effects upon public health efforts in many countries, particularly in the area of mental health. For governments facing structural adjustment and other imposed economic belt-tightening, an emphasis on pharmaceuticals appears a faster, often cheaper solution than clinical engagement and care giving. In keeping with other neoliberal economic-inspired reforms, as a public health initiative pharmaceuticalization moreover represents a giant step backwards from addressing the structural causes of disease prevalence (Nguyen and Peschard 2003).
In a pioneering study of global health politics in Brazil, Biehl investigates the negotiation between the neoliberal state and market forces that results in the pharmaceuticalization of public health in that country (2007). He reports upon the transactions between the Brazilian government and the pharmaceutical industry in the effort to build a biotechnology policy that would stanch the destruction being wrought by AIDS. The Brazilian government managed to both “challenge the patent and pricing structures of global pharmaceutical companies” and to coordinate an alliance of partners, including pharmaceutical companies, to accomplish some of its objectives. Yet it is clear to Biehl how pharmaceutical companies “engage in biopolitics, gaining legitimacy and presence in both state institutions and individual lives through drugs.”
“The pharmaceutical industry’s capacity to neutralize and redirect any form of counter-reaction to its advantage is indeed remarkable. Just as big pharma has played a key role in setting global trade rules (through TRIPS, for example), it has also helped to shape the international health agenda. The advocates of the neoliberal reforms of the 1990s encouraged the participation of the private sector in resolving social problems. Nevertheless, this discourse of corporate social responsibility did not translate into large-scale partnerships to eradicate disease among the global poor. But it definitively enabled the private sector to enter the decision-making process at institutions of global governance, and from there to defend its interests and vision.” [2007:1099]
Pharmaceuticalization in Brazil proceeds as a strategic and indeed highly culturalized process of expansion. There may be all manners of public/private partnerships proposed and accepted by the Brazilian government, but in the end there remains a competition between business and government for the simple reason that many of their goals do not coincide.
This competition between business and public health goals was evident to me in my investigation of the introduction of SSRI antidepressants in Japan in the early 2000s (Applbaum 2006). The elements of the ground-preparing pharmaceuticalization program, greatly aided by PhRMA’s participation, included: (1) Rhetorically accentuating the purported deficiencies in the treatment of Japanese sufferers from mental disorders. (2) Coordinating the efforts of supposedly competing firms to “make the market.” (3) Deploying transnational institutions such as ICH and patient advocacy groups to help impose global criteria for Japanese healthcare reform. (5) Provoking, through lobbying the Ministry of Health, Labor and Welfare, internal debates about healthcare reform and Japanese drug company competitiveness. These actions were predominantly ethical in character, once again showing how ethical discourse is frequently mobilized in pharmaceutical company growth strategies.
Pharmaceuticalization functions as a three-way bridge among the universalizing assertions of biomedical science, the moral imperative to treat the world’s sick, and the subjective experience of illness. The pharmaceutical industry claims privileged access to each of these three domains. Science, through vaunted boasts about how much it spends on R&D; through the enactment of clinical trials; and by wagging the frayed banner of twentieth century pharmacological successes in the public’s face and saying, “See, we are the saviors of mankind!” This is simultaneously an ethical claim. The industry coordinates efforts (among patient advocacy groups, for instance) to lobby public health authorities that hesitate to pay top dollar for the latest pharmaceuticals, rebuking them for withholding the fruits of progress from suffering constituents.
The industry finally claims its exclusive connection to the subjective experience of illness on grounds of its intimate understanding of quality of life issues, an aspect of the illness experience notoriously disregarded by the medical profession. This is the segue to promulgating marketing-defined need concepts including risk management, lifestyle appeal, consumer choice, and trust that the West’s branded medicines are efficacious and the most advanced. By these means, the industry has advanced rapidly in its campaign to incorporate human suffering and medicine’s best intentions to alleviate it into the depersonalized, privatized calculus of growing the market for pharmaceuticals.
Applbaum, Kalman. Educating for Global Mental Health: American Pharmaceutical Companies and the Adoption of SSRIs in Japan. In Pharmaceuticals and Globalization: Ethics, Markets, Practices. Petryna, Adriana, Andrew Lakoff, Arthur Kleinman, eds. Duke University Press, 2006, pp. 85-111. Available at: http://www.uwm.edu/Dept/Anthropology/medical/applbaum_global.pdf
Biehl, João. Pharmaceuticalization: AIDS Treatment and Global Health Politics. Anthropological Quarterly (2007) 80(4): 1083-1126, p. 1085. Available at: http://muse.jhu.edu/journals/anthropological_quarterly/v080/80.4biehl.pdf
Vinh-Kim Nguyen and Karine Peschard. Anthropology, Inequality and Disease: A Review. Annual Review of Anthropology (2003), 32: 447-474. Available (by subscription) at: http://arjournals.annualreviews.org/doi/abs/10.1146/annurev.anthro.32.061002.093412