34038191.pdf

(95 KB) Pobierz

Sociology of Health & Illness Vol. 30 No. 6 2008 ISSN 0141–9889, pp. 813–824

doi: 10.1111/j.1467-9566.2008.01123.x

Simon

Original UK

XXX Foundation Ltd

1467-9566

0141-9889of Health for the Sociology of Health & prospects

Sociology Publishing& IllnessGabe progress Davis

SHILsociology of pharmaceuticals: and Peter and Illness/Blackwell Publishing Ltd

The

Oxford,

BlackwellWilliams,

The sociology of pharmaceuticals: progress and prospects

Simon J. Williams

, Jonathan Gabe

and Peter Davis

Department of Sociology, University of Warwick

Department of Health and Social Care, Royal Holloway, University of London

Department of Sociology, University of Auckland, New Zealand

Abstract

This paper takes a critical look at progress and prospects regarding the sociology

of pharmaceuticals over the years. Key themes examined include: (i)

medicalisation and pharmaceuticalisation; (ii) regulation; (iii) consumption and

consumerism; (iv) expectations and innovation. Papers in the monograph are also

introduced and discussed in relation to these themes. The paper concludes with

some further comments and reﬂections on progress and prospects in this ﬁeld,

emphasising the continuing importance of sociological engagement with these

personal and political issues in the 21

century.

Keywords:

pharmaceuticals, medicalisation, pharmaceuticalisation, regulation, consump-

tion, consumerism, expectations, innovation

Introduction

Recent years have witnessed an upsurge of interest in pharmaceuticals and society, a trend

which in part reﬂects the growing power and inﬂuence of the pharmaceutical industry over

all our lives, as patients, consumers and citizens. Medicine costs the National Health

Service (NHS) in England alone over £7 billion every year, 80 per cent of which is spent

on branded (patented) products, with the pharmaceutical industry the third most proﬁtable

activity in the UK economy after tourism and ﬁnance (House of Commons Health

Committee 2005). These ﬁgures, in turn, are part and parcel of the bigger global picture

of pharmaceuticals sales which are forecast to grow by ﬁve to six per cent between 2007 and

2008 to over US $735 billion a year – with North American sales alone constituting nearly

half of this market, and North American and European pharmaceutical sales together

constituting over three-quarters of global pharmaceutical sales (IMS MIDAS 2008 http://

www.imshealth.com). Scarcely a day goes by, moreover, without some story or other in

the media about pharmaceutical products and practices. On the one hand, newspaper

headlines boast new breakthrough ‘wonder drugs’. On the other hand, stories of drug crises

or controversies are regularly rehearsed in the media, thereby stirring fear and fascination

in the public mind as to the power of pharmaceuticals and the industry that markets and

manufactures them. Clearly pharmaceuticals have an important role to play in the alleviation

of human suffering and the saving of lives. They are also, however, the source of much

controversy, contestation and conﬂict, not simply in terms of their development, testing

and marketing, but in terms of their very meaning and consumption.

This monograph is both a reﬂection of and response to this upsurge of interest in

pharmaceuticals and society, casting further critical sociological light on these developments,

Published by Blackwell Publishing Ltd., 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA

814

Simon J. Williams, Jonathan Gabe and Peter Davis

discourses and debates. It is possible, in this respect, to point to a variety of themes and issues

which taken together demonstrate both progress in sociological research on pharmaceuticals

over the years and future prospects.

Medicalisation and pharmaceuticalisation; doctors, disorders and drugs

The ﬁrst and perhaps most long-standing sociological theme has centred on the role of

pharmaceuticals in the medicalisation of society. When Illich (1975), way back in the 1970s,

talked of the iatrogenic effects of modern medicine and how the consumption of medical

products helped sponsor a ‘morbid society’, a key target of his critique was our ‘over-

reliance’ or ‘dependence’ on drugs as well as doctors. Others more fully or squarely located

within medical sociology, particularly North American medical sociology, have also taken

up these themes, albeit in a less radical or libertarian way than Illich. Speciﬁc emphasis has

been placed by these authors on the expansion of medical jurisdiction and control over more

and more areas of our lives, in the name of health and illness (Zola 1970, Freidson 1970,

Conrad and Schneider 1980a,b). The role of the pharmaceutical industry within these

processes, nonetheless, remained a somewhat muted or neglected theme in the medicalisa-

tion literature of the 1970s through to the 1990s, with sociological attention focusing

on the power and inﬂuence of medicine in the social construction of disease and decisions

about its treatment. More recent work, however, has begun to reappraise these processes

in the light of current trends and developments regarding the medicalisation of society.

Conrad (2005, 2007, Conrad and Leiter 2004), for example, in updating his previous

work in this area (Conrad 1992, Conrad and Schneider 1980a,b), has pointed to what he

terms the ‘shifting engines’ or ‘drivers’ of medicalisation over time – see also Clarke

et al.

(2003) for a somewhat different line or emphasis on transitions from medicalisation to

so-called ‘biomedicalisation’. Whilst the deﬁnitional centre of medicalisation remains with

doctors, Conrad argues, the primary drivers of medicalisation now pertain to consumerism,

managed care markets and developments in biotechnology, including the pharmaceutical

industry.

Other more critical commentators (many of whom, signiﬁcantly, are not sociologists),

have taken these arguments one or more steps further, claiming that what may once have

been regarded as medicalisation is now best seen as outright ‘disease-mongering’ in which

the helping hand of the pharmaceutical industry looms large. Critics such as Moynihan

(Moynihan 2002, Moynihan and Henry 2006, Moynihan

et al.

2002) and Blech (2006), for

example, through a series of case studies, have shown how pharmaceutical companies in

collaboration or conjunction with doctors, pressure groups and the media, are no longer

simply manufacturers of drugs but of diseases for these drugs to treat! – see also Law (2006)

on ‘Big Pharma’. A recent issue of the

Public Library of Science – Medicine

, for instance,

devoted a whole section to essays on this very issue, including case studies of a range of

diseases or disorders from ADHD (Phillips 2006) through erectile dysfunction (Lexchin

2006) and female sexual dysfunction (Tiefer 2006) to bipolar disorder (Healy 2006). These

critiques, to be sure, are important. Not all forms of medicalisation, however, involve

disease-mongering. Nor do all forms of medicalisation entail pharmaceuticals or processes

of pharmaceuticalisation. Ideally, medicalisation should be considered as a value-neutral

term that simply denotes the making or turning of something into a medical matter, the

merits of which are open to empirical investigation depending on the case in question

(Conrad 2007, 1992). Medicalisation, as such, may have positive and negative or light and

dark faces, involving both gains and losses for the parties involved.

The sociology of pharmaceuticals: progress and prospects 815

Whatever the merits of the case for outright disease mongering, one key vehicle for the

expansion of pharmaceutical markets is of course direct-to-consumer advertising (DTCA):

a development which to date is limited to countries such as the USA and New Zealand.

On the one hand, this may be viewed as an entirely new development or departure. On the

other hand, an instructive parallel and precursor may be found in the guise of patent

medicine advertising in the past. Conrad and Leiter’s paper, for example, sheds valuable

further light on these issues. Taking two advertising exemplars as its case studies – the late

century Lydia E. Pinkham’s vegetable compounds for ‘women’s complaints’ and

contemporary Levitra for ‘erectile dysfunction’ (ED) – instructive parallels are drawn by

these authors between the patent medicine era and the DTCA era. One of the great ironies

of DTCA in this respect, Conrad and Leiter argue, is that it extends the relationship of

drug companies, physicians and consumers in ways that rehearse or return us to a situation

similar to Lydia Pinkham’s day, when the drug manufacturers had a direct and independent

relationship with consumers. Whilst the extravagant claims of Pinkham are now constrained

by law, moreover, we must also contend with the fact that modern advertising has

become far more subtle and sophisticated in its attempts to persuade or convince

consumers that its products are the right ones in an increasingly competitive pharmaceutical

marketplace. The pharmaceutical industry and consumers, Conrad and Leiter conclude,

are increasingly important players in medicalisation, facilitated in part by the advent (or

return to) DTCA.

Another key factor or player in these medicalising processes, of course, as Conrad and

Leiter’s paper on DTCA clearly attests, are the media. Previous sociological studies, for

example, have demonstrated both celebratory and critical media discourses on drugs,

depending on the media, format and drug in question, the relative ‘newness’ of the drug to

the market, and its ‘newsworthiness’. For example, when benzodiazepine tranquillisers were

ﬁrst prescribed in the 1960s they generally received an enthusiastic welcome in the UK and

US media and were proclaimed as heralding a new therapeutic era. As their popularity

grew, however, their therapeutic value ceased to be newsworthy and a more critical coverage

developed, drawing on the comments of a small but growing band of professional and lay

critics. Initially, in the 1970s, this concern focused on claims about their overuse as a

‘chemical crutch’ for personal problems, before shifting in the 1980s and 1990s to claims

about these drugs’ ‘addictive’ potential, (Gabe and Bury 1996a, 1996b), with users

portrayed in the local and national UK press as innocent victims, through no fault of

their own, who then tried to withdraw and embark on a ‘return journey’ to normality

(Gabe

et al.

1991). Moreover, through these forms of mediation and marketing, drugs may

come to take on personalities of their own, achieving some sort of quasi-mythic or celebrity

status in the popular imagination, construed or constructed as the archetypal hero or

villain (see for example Martin 2007, Nelkin 1995).

Some of these issues, for instance, are addressed in Williams and colleagues’ paper on

newspaper coverage of the wakefulness-promoting drug Modaﬁnil (brand name Provigil).

Constructions of this drug in the print news media, these authors show, range from largely

uncritical endorsement of its clinical applications as a ‘breakthrough’ or ‘wonder drug’ for

a growing list of sleepiness-related conditions, to somewhat more cautious or critical

coverage of its wider (potential) uptake as a lifestyle drug of choice, or in sport or military

contexts. Again, we see here, in the guise of this wakefulness-promoting drug, the now

familiar if not commonplace rehearsal of concern over the blurring or shifting boundaries

between ‘treatment’ and ‘enhancement’, and the broader articulation of cultural anxieties

about a move to a 24/7 society in which sleep becomes increasingly optional if not obsolete.

A notable feature of the paper, in this respect, is the authors’ preference for the term

816

Simon J. Williams, Jonathan Gabe and Peter Davis

‘pharmaceuticalisation’ rather than medicalisation in order to capture these concerns in

the press: concerns, that is to say, to do with the potentially widespread use and uptake of

pharmaceuticals for diverse purposes which extend far beyond the realms of medicine or

the strictly medical.

Another prime expression of the mediation of pharmaceuticals, of course, concerns the

Internet or cyber-space/culture – see, for example, Miah and Rich (2008). This includes not

simply access to information on pharmaceuticals via Internet searches, but the purchase of

pharmaceuticals through online or e-pharmacies and the sharing of information and

support through Internet chat rooms and online forums of various sorts (Fox

et al.

2005a,b).

In these and other ways, new opportunities for the mediation of pharmaceuticals are

opening up in all our lives, for better or worse, routes that may very well bypass the traditional

doctor-patient relationship altogether. Some of these issues, for example, are taken up in

Fox and Ward’s paper on the pharmaceuticalisation of daily life – as with Williams

et al.

’s

paper, the preference for pharmaceuticalisation over medicalisation is once again notable.

Taking as their problematic the new emphasis on lifestyle in the production, marketing and

consumption of pharmceuticals and drawing on a diverse array of sources – including

literature from social science, economics and health services research, together with their

own research on pharmaceutical consumption – Fox and Ward identify two broad

processes at work here. First, a domestication of pharmaceutical consumption, through

computer mediated access and consumption within the home, particularly the bedroom

and the kitchen. Second, the pharmaceuticalisation of everyday life, as pharmaceuticals

come to be seen by consumers as ‘magic bullets’ for a range of everyday daily life problems.

The domestication of pharmaceutical consumption and the pharmaceuticalisation of

life, in this respect, become a complex mixture or heady brew of factors, including the

biological effects of the drug on the body, the legitimacy of the problem or disorder in

question, the willingness of consumers to adopt the technology as a ‘solution’ to a problem

in their lives, and the corporate interests of the pharmaceutical industry. For these authors

social relations surrounding contemporary pharmaceutical production and consumption

‘link the world of business to the private world of citizens, forging new diseases and treatments

from the very fabric of daily life’.

Regulation; science, politics and the pharmaceutical industry

If medicalisation and pharmaceuticalistion constitute one key strand of sociological

research on pharmaceuticals and society over the years, then the science and politics of the

pharmaceutical industry, including issues of development, testing and regulation, constitute

another rich seam of work. Abraham (1993, 1995, 1997, 2002, 2007, Abraham and Davis

2005, Abraham and Lewis 2002, Abraham and Reed 2001, Abraham and Sheppard

1999), for example, has been at the forefront of this research over the past 15 to 20 years,

documenting through detailed empirical case study work and comparative analysis elements

of controversy and corporate ‘bias’ which, at one and the same time, demonstrate the

inadequacies of existing regulatory practices and procedures, and the need for more rigorous

and robust policy interventions at the institutional and legislative levels. These include the

development of independent drugs testing by regulatory authorities, increased patient and

public representation on regulatory committees and more frequent and thorough oversight

of regulatory performance by the legislature – see also Busﬁeld’s (2007a) recent sociological

analysis of scientiﬁc ‘fact making’ in the clinical trials of drugs and in post-approval drugs

assessment, and the subsequent Abraham (2007)-Busﬁeld (2007b) debate.

The sociology of pharmaceuticals: progress and prospects

817

Many of these issues were explicitly taken up and addressed by the House of Commons

Health Committee (2005) Report on

The Inﬂuence of the Pharmaceutical Industry

. Whilst

rightly noting how pharmaceuticals may be a force for the good in contributing to the

health of the nation, the report is nonetheless peppered with references to a ‘failing’

regulatory system, to ‘lax oversight’ and to practices on the part of the pharamaceutical

industry which ‘act against the public interest’, given the power and inﬂuence of marketing

forces. Recommendations cover several key areas, including the licensing process, with

greater transparency and independent assessment of evidence, improved Medicine

and Health Care Products Regulatory Agency (MHRA) mechanisms for restraints on

medicines promotion, tougher restrictions and greater vigilance to guard against ‘excessive’

or ‘inappropriate’ prescribing, and a fundamental review of the MHRA itself.

In revisiting these issues, Abraham’s paper provides both a timely review of 20 years of

sociological research on pharmaceutical development and regulation and a reassertion of

the importance of a realist empirical research programme for the investigation of these

issues, based on the notion of ‘objective interests’ –

i.e.

the objective interests of pharma-

ceutical companies in proﬁt maximisation and the objective interests of patients/public

health in the optimisation of the beneﬁt-risk ratio of drugs. Drawing on international

comparisons of drug regulation, Abraham shows how commercial interests have biased the

science of drug testing and review away from patients and the public in favour of the

industry: a process, he argues, which is best characterised as ‘neo-liberal corporate bias’.

Far from being the ‘inevitable by-product’ of technoscientiﬁc progress in pharmaceuticals,

moreover, these international comparisons are valuable in demonstrating considerable

scope for improvement. Similarly, the lowering of technoscientiﬁc standards for drug safety

across the EU, US and Japan is not, Abraham argues, an inevitable price to be paid for

faster development of therapeutically valuable medicines, but more plausibly a consequence

of the international spread of neo-liberal corporate bias in pharmaceutical regulation.

The gender and sexual politics of pharmaceutical development, testing, and regulation

adds another important dimension to the picture here. We see this very clearly, for example,

in Casper and Carpenter’s paper on the politics and controversy surrounding initiatives to

introduce the human papilloma virus (HPV) vaccine for cervical cancer in the United States

of America. These initiatives have, in the words of the authors, ‘animated longstanding

concerns about vaccination . . . and young women’s bodies and behavior’. The HPV

vaccine, in this respect, raises the spectre of both past controversies about vaccination and

current political concerns in the area of sexual morality. Vaccines, the authors argue, are a

distinctive kind of pharmaceutical invoking notions of ‘contagion’ and ‘containment’.

Pharmaceuticals, moreover, develop lives or biographies of their own; trajectories shaped

at every stage or phase by politics. Viewed in this light then, it is not so much the public

debates about vaccination as such that are the most important dimensions to the story

here, but that its target is a sexually-transmitted disease, which thereby draws into the

debate issues of sex, gender and women’s bodies that are far more charged. The launch of

the HPV vaccine in short, these authors argue, appears to have ‘inﬂamed’ US health care

politics which in turn has affected plans for marketing the drug. This in turn underlines

both the struggles provoked by this new gendered technology and the ever emerging and

evolving ‘biographies’ of pharmaceuticals themselves, which to repeat, are deeply political.

Broader questions also arise at this point about the global nature and dynamics of the

pharmaceutical industry. These include debates on the ‘globalisation’ of medicines control

(Abraham and Reed 2003), whether or not the pharmaceutical industry is in fact truly

‘globalised’ in the ﬁrst place – multinationalisation, or Westernisation, Busﬁeld (2003)

argues, are more accurate terms of reference – and the growing practice of out-sourcing or

Plik z chomika:

VkV

Inne pliki z tego folderu:

18615424.pdf (54 KB)
1978_The Sick Role - Assessment and Overview.pdf (388 KB)
1992_Medicalization and Social Control.pdf (2647 KB)
2005_The Shifting Engines of Medicalization.pdf (463 KB)
26642509.pdf (168 KB)

34038191.pdf

Plik z chomika:

Inne pliki z tego folderu:

Inne foldery tego chomika: