by Joseph Dumit
Duke University Press, 2012. pp. 280.
Since the 1970s, scholarly work on pharmaceuticals has long engaged a number of concerns, debates and controversies: the socialities and politics of consumption, the commercialization of the life sciences, and restricted access to life-saving medicines as a result of global patent and trade laws – to name a few.
In his book, Drugs for Life, Joseph Dumit completely resituates our understanding of a highly studied topic. A key critical intervention is his ethnographic approach. Pharmaceuticals, drug companies, health care systems, and doctor-patient interactions are not sites of ethnographic inquiry per se – even though they are completely integral to the story. Rather, the ethnography focuses on the drug industry’s shifting logics — from former investments in individual health to future-oriented investments in mass health. As a result, the project is located within an entirely unique scale of analysis such that individual patient subjectivities are effortlessly tied to strategies for making drug markets grow.
From this methodological approach, we learn that pursuing high rates of economic growth requires the drug industry to reimagine medicine itself. Medicine is no longer exclusively about enhancing individual health, especially acute symptoms for which treatments end when health is restored. But rather it is more about treating health risks at a larger, aggregate scale. Health risks are quantifiable thresholds that connect cholesterol levels to heart conditions, glucose levels to diabetes, blood pressure to hypertension, etc. High-risk thresholds can be indefinitely symptomless yet projected as always life-threatening. The industry recognizes that getting more people on more prescription drugs is key to expanding market growth; and focusing on health risk presents novel ways to get patients to indefinitely take treatments. Importantly, health risks themselves can be highly flexible in ways that increase long-term market share. For example, Dumit describes how the risk thresholds for cholesterol have been lowered three times over the last decade, increasing the potential to get more patients prescribed more cholesterol-lowering statins.
Much work must go into producing these logics. Dumit shows how the patient is viewed from marketing perspectives as inherently ill, always at risk; she is constructed as responsible for taking charge of her preventative care – what Dumit refers to as “objective self-fashioning” (see also Dumit’s Picturing Personhood, Princeton University Press, 2004). Patients and doctors are not fools in this scenario, but rather they are congealed into drug industry “facts” that result in a small range of treatment options. Such facts are generated by clinical trials that are designed to create evidence for more treatment and ultimately larger market share. For example, a clinical trial may indicate that hundreds of asymptomatic people should take a daily pill in order to prevent a handful of heart attacks – the individual is treated but the mass-produced data estimates aggregate health risk and quantifies market potential. Some trials fail to show such “good” results, but as Dumit points out, clinical trials never study when a patient should stop taking a drug, which would be the end to this strategy for maximizing prescriptions.
The key concept in Drugs for Life is “surplus health,” which Dumit defines as ‘the capacity to add medications to our life through lowering the level of risk required to be “at risk.”’ Dumit shows how surplus health operates throughout the book, as I have briefly illustrated, but he leaves out some key theoretical work that he conceptualized elsewhere (see “Prescription Maximization and the Accumulation of Surplus Health in the Pharmaceutical Industry: The BioMarx Experiment” that appeared in Lively Capital: Biotechnologies, Ethics, and Governance in Global Markets, Ed. Sunder Rajan, Duke University Press, 2012). It is worth exploring because surplus health has implications for a wide range of issues in medical anthropology and science and technology studies.
Dumit describes the shift from individual health to mass health when medicine “as an arm of capital (charged with maintaining workers for work) became an industry itself…” (“Prescription Maximization”, 52-53). In reading Marx, Dumit discusses how early capitalism needed healthy workers because they were essential to industrial production. That is, medicine was critical to reproducing the conditions that made healthy workers possible. Dumit compares Marx’s analysis of commodity production to surplus health. Marx argued that commodity production became a self-perpetuating means to an end, geared toward primarily generating surplus value. Similarly, Dumit shows that ‘health for workers’ shifts to ‘health as an industry in and of itself,’ one also geared toward the generation of surplus value. He writes:
The healthcare industry has its own imperatives for growth that on the face of it are contradictory to capital; that is, healthcare grows by treating more illnesses, yet it should not remove workers from the workplace. The solution is to appropriate that part of health that is not needed for work. This surplus health includes those persons who are too young or too old to work, and it includes illnesses that can be treated “on- the- job,” so to speak, without keeping the worker from working. The latter encompasses both illnesses of the everyday (like mild depression) and illnesses of the future (like risk factors and symptomless illnesses like cholesterol). Each of these areas of illness can easily be shown to be major targets of diagnostic and therapeutic development, and each has had phenomenal growth in the last fifty years, intensifying especially in the last decade (“Prescription Maximization”, 52-53).
This conceptualization is critical to understanding just how pharmaceutical value works in almost classic Marxian contradiction: patients who are healthy and do not take medicine are not valuable to this drug economy. What is valuable is the construction of the inherently ill, at-risk patient who recognizes the chronic need to take pharmaceuticals over the long-term – taking drugs now is the key to future good health and future productive markets.
Drugs for Life is a brilliant and provocative analysis of the new cultural and business logics of science, medicalization, and the drug industry. While it largely focuses on the U.S., it has further implications for how we understand the circulation and social meaning of pharmaceuticals in other regions. Drugs may encounter similar or different sets of industry logics throughout the world, but such logics are nevertheless geared toward ensuring market share, pricing strategies, and market expansion. It is, in sum, an inspiring and generative book that is certain to spark future significant inquiry.
Kristin Peterson is an associate professor of anthropology at UC Irvine. She is the author of Speculative Markets: Drug Circuits and Derivative Life in Nigeria (Duke UP, 2014).