Transcript Beyond medicalisation: The pharmaceuticalisation of society

The Sociology of Pharmaceuticals
Jonathan Gabe
Royal Holloway, University of London
Early studies
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Pharmaceuticals been given relatively little
consideration to date by sociologists.
Surprising given the importance of medicines for
treating illness and disease
Early studies in UK descriptive – surveys of
medicines kept at home
1980s - micro level qualitative studies of patient
experience of particular medicines – Benzos –
Valium etc
1990s - macro level institutional studies of
Medicines Regulation – extent to which
regulators have been captured by Big Pharma
Two Examples of Contribution
Sociologists can make
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Macro level theoretical work to understand
the growing power of the Pharmaceutical
Industry
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Micro level empirical work on the
Medicines Use in the Home
1. Pharmaceuticalisation of
Society?
Medicalisation a key concept in med soc
- how non medical problem becomes defined as
medical,usually in terms of illness (childbirth,
alcoholism etc)
 Employed in both professional and lay discourse
 Not static concept
 Recent emphasis on changing drivers
 Growing recognition of role of pharma industry,
targeting public as well as physicians.
 Do we need a specific concept to understand
the growing role of big pharma?
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What is Pharmaceuticalisation?
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Complex, dynamic, socio-technical
process
Involves discovery, development,
commercialisation, use & governance of
pharma products
Centred on chemistry based technologies
Definition
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Definition – Transformation of Human
Condition / Capabilities into opportunities
for Pharmaceutical Intervention
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Processes stretch beyond the medical
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Include non medical uses – lifestyle
enhancement amongst the healthy
Relationship to Medicalisation (1)
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Complex and contingent
Can have pharmaceuticalisation without
medicalisation
Both value neutral terms - gains and losses
Both involve matters of degree / extent
Open to empirical exploration – case by case
Both can be partial - incomplete
Relationship to Medicalisation (2)
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Involves
a) macro level processes – development /
testing / regulation of pharmaceuticals
b) micro level – meaning & use of pharma in
medical practice & everyday life
Bi-directional – like medicalisation – depharmaceuticalisation – but in practice usually a
matter of one drug replaced by another.
Can have resistance and advocacy
Six dimensions of
pharmaceuticalisation
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Focus on recent changes making the use
of drugs more pervasive
Reveals why pharmaceuticalisation
increasingly important.
Provides a basis for criteria to measure
the extent of this process in any given
case
6 Dimensions of
Pharmaceuticalisation
1.
2.
3.
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Selling sickness – the claim that health
problems have a pharma solution
Changing forms of governance – regulators
and the promotion of innovation
Reframing health problems in media/popular
culture as having a pharma solution
Role of patients/consumer groups
Use of drugs for non-medical purposes
Pharmaceutical futures
(1) Selling sickness – the claim that
health problems have a pharma solution
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Massive growth in drug markets – especially
USA & Europe
Highly profitable – 25% per year in 1990s for
most companies
Drug sales tripled in US between 1980-2000
Sales uneven across the world – chronic health
problems in ageing affluent societies –
Disease mongering (Moynihan) – widening the
boundaries of treatable illness e.g. restless leg
syndrome
(1) Selling sickness (contd)
Disease mongering – value laden.
 Analytic value restricted
 Pharmaceuticalisation may/may not
involve disease mongering
 Direct to consumer advertising – US & NZ
Another way to expand the pharma market
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(2) Changing forms of governance – regulators
and the promotion of innovation
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Changing relationship between regulators and the
industry
Reduced regulatory hurdle & increased dependency of
these agencies on industry
- reduced regulatory review time & fast tracking of drugs
for life threatening diseases
- regulators competing for custom of companies
New policies to increase role of regulators in promoting
drug innovations
– help combat productivity crisis in big pharma
Globalisation of governance based on interests of
pharma – increased harmonisation
(3)Reframing of health problems in media / popular
culture as having a pharma solution
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Media co-opted into disease mongering – e.g.
exaggerate prevalence of a `disease’ (restless
leg) & need for drugs
Media may legitimate need for drugs but also
express critical voices – expose drug co
activities
Internet as a channel for pharmaceuticalisation
of daily life (e.g Viagra for sexual potency) but
also a space to challenge practices – proanorexia websites
(4) Role of patients/consumer
groups
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Users of drugs as knowledgeable actors –
assessing risks and benefits
Potential for resistance and for aiding
pharmaceuticalisation
Self help/ patient advocacy orgs
– may support or challenge drug cos.
- critics have had minimal success
– those seeking access to drugs much more
successful (Herceptin, Beta Interferon)
– reflecting the power of the industry
(5) Use of drugs for non-medical
purposes
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Three types of biomedical enhancement
(Conrad)
A) normalisation – enhancements to make
`normal’
B) repair – restore to previous condition
C) augmentation – to boost performance – use
of Modafinil to improve cognitive performance –
giving people an `edge’
Way to expand drug market through direct
relationship with consumer, outside control of
medical profession
(6) Pharmaceutical Futures
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How expectations about the future shape the
present – hope invested by patients in
breakthroughs
Pharmacogenetics – claims about tailor made
meds, reducing adverse drug reactions
Policy planning on this basis, crowds out
alternative futures - biomedicine still dominates
But progress slow & productivity crisis in the
industry
Conclusions on
Pharmaceuticalisation (A)
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Pharmaceuticalisation – complex and dynamic –
involving a range of actors
6 dimensions identified
Common features across these dimensions
A) Expansion of drug markets outside traditional
areas – new medical conditions, new
applications in the healthy
B) Increasing dominance of state regulators
C) Moves to bypass medical profession
D) Colonisation of daily life by pharma solutions
Conclusions on
Pharmaceuticalisation (B)
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Pharmaceuticalisation intensified in recent
decades
Relationship between industry, state and
medical profession complex – limits industry
power
Resistance to pharma expansion from media,
state, patients
Taken together = picture distinct from
medicalisation in important respects
Highlights its value as a sociological concept
2. Locating Drugs Domestically –
a case study from New Zealand
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Potions and elixirs have been revered for
millennia
Meaning of meds complex – ambivalence – faith
– suspicion
Not just material objects but invested with
history – including use in the home
Location within `domestic therapeutic landscape’
speaks to processes of emplacement, rouines,
identity and care
What do people do with medicines in their
homes?
MEDICATIONS AS SOCIAL
OBJECTS
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Limited research into spatial, material practices
involved in the everyday use of medications in
domestic settings
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Important because home furnishes people with a
distinctive social space for self-care and selfmedication.
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Yet undertaking this research difficult because medicine
use in the home likely to be `taken for granted’.
PRESENT
STUDY
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Use multi-methods to get behind routines
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20 diverse households = group discussions, observations,
mapping, photographs, diaries, interviews.
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Home exists in broad sociopolitical context [public/private]
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Medications have meaning before entering the home
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Two core issues:
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1. How medications incorporated in everyday life
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2. How meds linked to identities and care-giving
Two themes from the data
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How medicines incorporated in everyday
life at home
2.
Identity and care
1. HOW MEDICINES INCORPORATED
IN EVERYDAY LIFE AT HOME
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Extent meds embedded in home revealed when
respondents rediscovered old meds
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E.g. when talking about photo of storage bin in
bathroom
- 2 adults + three children
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Think out loud – remember purpose & origins
EMPLACEMENT OF
MEDICATIONS
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Bev: It’s got basically things we don’t generally
look at. It tends to have a lot of pain killers so
it’s got– my physio used that for my knee. It’s
got – what is that? Oh, that was when the
doctor gave us that for Phoebe’s tummy, but we
never took it. Remember when she was getting
that – did she have this thing with her tummy or
did she not? […]
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Bev: … This has actually got a whole batch of
stuff even from when Steve, we have to sort
this out, it’s embarrassing… Look at it. Who
had Erythromycin – oh, that was when Phoebe
had, when she had her asthma…
RUMMAGING THROUGH MEDS
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When people handle meds they are translated into social
objects –
- meds carry personal / shared meanings and identities
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Objects act as memories - transporting people back into
past events and experiences
 Next slide – respondent rummaging in box of expired
meds
RUMMAGING THROUGH
MEDS
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Zoe: This one is Medipulv antiseptic powder so probably
used that for chaffing… This one is peroxide – good old
peroxide 1993. […] So, it was something to do with my throat
because I was gargling it… This is pre-used by dates. So,
Panadol, Panadol, Panadol, night caplets [pain relief]. And
that one is a, that one’s actually quite good for helping you
sleep, I think.[…]
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.. And I have my diclofenac, so that’s my painkiller generic
brand – that’s the Voltaren. I originally had Voltaren when I
had knee surgery. And I had a lot left over. Then I had painful
gall stones and I would have used it then..
PLACE OF MEDS IN DAILY ROUTINE
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Strategic placement crucial in reminding
people to take their medications when they
are having breakfast or going about life.
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Ailments are reconstituted daily through
placement and routinization of use
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Bench common to household processes of
remembering and compliance
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Placement renders objects intelligible
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Not just about `compliance’ but enactment of
relationships and communal routines
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Routine gives sense of certainty and control
2. IDENTITY AND CARE
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Meds intertwined with experiences of being in the world
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Where placed an expression of self and relations
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Terms like `my pills’ = statement of ownership / degree to
which pills part of `us’
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For chronically ill meds central to the self – provide a
sense of certainty
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E.g of discussion in household of 4 young people.
IDENTITY AND CARE
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Jenny: Obviously medication is my life… I’ve been on
dialysis for 19 years so that’s 19 years of prescription
drugs. That’s a long time.. At times I’ve had a love/hate
relationship with medications… It’s a necessary evil in
my life. Sometimes that’s the way I see it and then other
times it’s routine. It’s like getting up and brushing your
teeth… I’ve taken it for so long that I actually don’t know
what I’d do with myself if I didn’t have to take anything
CARING AND SHARING
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Caring by giving medicines to others
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Reaffirm bonds between household members
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Expressed through affection, affiliation and humour.
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e.g household discussion about reminding each other to
take their meds
CARING AND SHARING
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Billie: Sometimes Mum might say “..Did you forget to take
that?” or “Is that meant to be there?”
Mel: You know how you might put it down by your breakfast
and forget to pick it up.
Billie: Or she might tease me, “Are you sure you took your
pill?”
Mel: Yeah (laughter). You could take the pill (laughter)
Billie: We’re pretty good, we muddle through.
Mel: We just go off in a snot with each other! (laughter)
Billie: No, we don’t! (laughter)
Mel: You do! (laughter)
Billie: I do. (laughter)
Mel: Yes. “Don’t talk to me.”…
DISCUSSION
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Meds interwoven into households
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Taking of meds taken for granted like having a cup of tea
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Emplacement of meds reflects
relationships and uncertainties of
illness
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Meds bound up in relationships
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People transform pharmacological
objects into social objects with
histories and memories
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Meds central to reconstruction of
home as space of care
Conclusion
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Sociology of Pharmaceuticals now starting
to make more of a contribution.
Contribution both theoretical and empirical
Contribution at Macro level and Micro level
Need to work at both levels to illustrate the
complex nature of relations between
pharmaceuticals and society.