It is worth quoting the exchange that gives this book its title. Near the beginning of his research on pharmaceuticals, anthropologist Joseph Dumit asked a leading clinical researcher “whether he was worried at all that the average American was on at least five prescriptions per year. His response was quick and sure: ‘I think being on five or more drugs for life is a minimum! Based on the latest clinical trials, almost everyone over thirty should be on cholesterol-lowering drugs.’”
On the basis of statements such as these, Dumit identifies a new model of health, and in Drugs for Life he explores its logic, especially through the marketing strategies of pharmaceutical companies. He draws on statements by marketers in trade publications such as Pharmaceutical Executive, uses these to reflect on the structure and consequences of clinical research, and shows how the images of health that he extracts are reflected in the industry’s advertising and the experiences of patients.
Once upon a time, people generally considered themselves healthy unless they felt ill, or had frailties or symptoms beyond normal ones. Two large changes have resulted in a new model of health. First, in the past half-century we have seen the rise of risk factors: familiar things such as diet, age and sleep patterns, and unseen and unfamiliar things such as cholesterol levels, positive BRCA1 and 2 genetic tests, and PSA (prostate specific antigen) readings. We are all at risk, differing only in degrees. Second, and partly as a result of the first change, we can be normal and unhealthy at the same time, at least when there is some hope for treatment. For example, the unfortunate results of ageing used to be just that but now we look for medical means to stave them off or treat them. Thus, there is no contradiction in the thought that most of us are less than healthy in this or that respect.
As a result, there is no limit to the potential demand for health. We are all always unhealthy. Most of the ways in which we are unhealthy are chronic, so treatments can extend for life. And since we are all unhealthy in so many ways, treatment - even successful - of risk factors or conditions allows us to focus on new problems.
Although these changes have been noted many times before, Drugs for Life approaches them as part of a new cultural logic around health. The result is provocative and allows Dumit to connect science, marketing, regulation and ethics in novel ways.
He identifies his topic as “the current American, middle-class, commonsense view of health and illness”, but the new model of health is bounded by neither nationality nor class. Dumit talks only about the US but the central claims and arguments of Drugs for Life apply throughout the developed world. The American middle class is only the most extreme in its adoption of the new model, and consequently in its drug consumption. In fact, the new model of health is a broadening and individualisation of the concerns of public health, and for that reason public health authorities often enthusiastically take up the logic that Dumit identifies.
The continuing expansion of treatment finds support in clinical trial results, at least as pharmaceutical trials are normally performed today. Dumit makes no claims that drug companies do poor science, lie about results of clinical trials or engage in fraud. However, the companies design trials with goals of establishing and increasing the size of markets, so they look for benefits of treatment in ever-larger populations. A trial of a cholesterol-lowering drug is a success, from the drug manufacturer’s point of view, if it shows the overall benefits of treating more people. According to the researcher quoted above, trial results show that everybody over the age of 30 can benefit from lowering their cholesterol, in the sense that they would be reducing their risk of heart attack. That wouldn’t mean zero heart attacks but only that putting an entire population on drugs would lead to fewer heart attacks than putting only a part of that population on drugs.
Dumit does not explain why the movement of trial data is always towards more treatment. In fact, it isn’t. Some trials fail to support more treatment and despite the fact that they are rarely designed to do so, the occasional one shows harm. Numerous trials of cholesterol-lowering statins suggest that they don’t help people who have no history of heart attacks, and that they can produce muscle damage and other side effects. But the pharmaceutical industry has enough influence over enough clinical trials to ensure that many are better designed to show benefits than harms. And it has enough influence over the promotion of knowledge within the medical world that commercially valuable trial results stand like bright flags on hilltops, whereas commercially damaging results usually lie less noticed on the ground, and sometimes are covered with mud.
Although its topic is an abstract one, much of Drugs for Life consists of insightful readings of advertisements, of statements by marketers and of patients’ accounts. Dumit has pulled together a tremendous number of telling arguments and phrases, and can be at his best when reading them. For example, he weaves together marketers’ statements to show that the pharmaceutical industry understands well that it profits more from treating risk factors than by curing disease, and he finds a classic anthropological rite of passage in an ad for the antidepressant Zoloft.
Marketing is not advertising. Marketing is the work that aligns products and consumers. It is a feat of marketing when an old drug such as Prozac can be reshaped and repackaged as Sarafem, to align it with the desires of hitherto hidden potential consumers with premenstrual dysphoric disorder. We get a new drug, new consumers and a new illness to connect them. Advertising can contribute to alignment but it often merely alerts or reminds consumers about a product, in an attempt to jockey for position.
Reading marketers’ bold and ingenious statements, one is apt to assume that they hold the power and the keys to reshape medicine for relentless profit. And indeed, drug companies often appear to be remarkably effective at implementing marketing strategies. However, there is a gap between the high-level statements of marketers and what doctors and patients do and believe. This book does not show how that gap is bridged - a fascinating topic on its own and one that might suggest strategies to resist exploitation of the new model.
Drugs for Life is uneven in places. Sometimes the author belabours the point, and sometimes his provocations deserve more argument - as when he introduces his idea of “surplus health”, part of a playful re-reading of Karl Marx that makes a few brief appearances in the book.
Drugs for Life concludes on a reflexive note. Dumit is highly critical of the new model of health and of the pharmaceutical industry’s promotion and exploitation of it - this is not a neutral, distanced analysis. Yet on its own terms, the new model is successful because it allows medicine to treat more illness. This leaves Dumit, the anthropologist, with the challenge of articulating the precise grounds of his unease. Interestingly, he does so by taking off his anthropologist’s hat and putting on a more medical one: he suggests that even while risk and illness are treated, health itself can be ill-served.
Professor of anthropology and director of science and technology studies at the University of California, Davis, Joseph Dumit “was born and grew up in the Chicago suburbs”.
“I now live in Davis, California, a quintessential college town and the bicycle capital of America. Riding 10 minutes to work year round is wonderful and peaceful. I live with Sylvia Sensiper, an artist, teacher and researcher, and our 17-year-old entrepreneurial son, Andrew.”
His interest in anthropology grew, he says, from “meeting friends in college and in a year abroad in Vienna, who were deeply into religions, businesses and social movements that I had never heard of”. This “activated a fascination with the amazing variety of what people love doing. Following their desires, learning how they enjoy what they do, the techniques of ‘getting into’ an activity, is what made anthropology so meaningful to me.”
Dumit has written on the digital world since the mid-1990s. Asked to point to the most striking developments in this realm, he says that “many science fiction books imagined constantly connected worlds but the lived diversity of chat, text, email, tweets and so on I didn’t grasp until it exceeded me - when my son got his first phone and somehow sent and received 11,000 texts in the first month. At least I had been warned by friends to get an unlimited plan.”
Of recent changes in US health policy, Dumit says: “Obamacare America is making healthcare more equitable, importantly by making sure that there is some healthcare available to everyone. But the longer-term problem of healthcare itself, and medical research being run for profit and therefore under imperatives to grow, is going to continue to create problems.”
Drugs for Life: How Pharmaceutical Companies Define Our Health
By Joseph Dumit
Duke University Press
280pp, £64.00 and £15.99
ISBN 9780822348603 and 48719
Published 25 November 2012