The Sociology of Pharmaceuticals Jonathan Gabe Royal Holloway, University of London

Early studies 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 Macro level theoretical work to understand the growing power of the Pharmaceutical Industry 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?

What is Pharmaceuticalisation? Complex, dynamic, socio-technical process Involves discovery, development, commercialisation, use & governance of pharma products Centred on chemistry based technologies

Definition Definition – Transformation of Human Condition / Capabilities into opportunities for Pharmaceutical Intervention Processes stretch beyond the medical Include non medical uses – lifestyle enhancement amongst the healthy

Relationship to Medicalisation (1) 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) 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 – de- pharmaceuticalisation – but in practice usually a matter of one drug replaced by another. Can have resistance and advocacy

Six dimensions of pharmaceuticalisation 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. Selling sickness – the claim that health problems have a pharma solution 2. Changing forms of governance – regulators and the promotion of innovation 3. Reframing health problems in media/popular culture as having a pharma solution 4. Role of patients/consumer groups 5. Use of drugs for non-medical purposes 6. Pharmaceutical futures

(1) Selling sickness – the claim that health problems have a pharma solution Massive growth in drug markets – especially USA & Europe Highly profitable – 25% per year in 1990s for most companies Drug sales tripled in US between 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

(2) Changing forms of governance – regulators and the promotion of innovation 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 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 – pro- anorexia websites

(4) Role of patients/consumer groups 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 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 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) 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) 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 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?

Limited research into spatial, material practices involved in the everyday use of medications in domestic settings Important because home furnishes people with a distinctive social space for self-care and self- medication. Yet undertaking this research difficult because medicine use in the home likely to be `taken for granted’.

Use multi-methods to get behind routines 20 diverse households = group discussions, observations, mapping, photographs, diaries, interviews. Home exists in broad sociopolitical context [public/private] Medications have meaning before entering the home Two core issues: 1. How medications incorporated in everyday life 2. How meds linked to identities and care-giving

Two themes from the data 1. How medicines incorporated in everyday life at home 2. Identity and care

1. HOW MEDICINES INCORPORATED IN EVERYDAY LIFE AT HOME Extent meds embedded in home revealed when respondents rediscovered old meds E.g. when talking about photo of storage bin in bathroom - 2 adults + three children Think out loud – remember purpose & origins

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? […] 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 When people handle meds they are translated into social objects – - meds carry personal / shared meanings and identities Objects act as memories - transporting people back into past events and experiences Next slide – respondent rummaging in box of expired meds

Zoe: This one is Medipulv antiseptic powder so probably used that for chaffing… This one is peroxide – good old peroxide […] 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.[…].. 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..

Strategic placement crucial in reminding people to take their medications when they are having breakfast or going about life. Ailments are reconstituted daily through placement and routinization of use Bench common to household processes of remembering and compliance Placement renders objects intelligible Not just about `compliance’ but enactment of relationships and communal routines Routine gives sense of certainty and control

2. IDENTITY AND CARE Meds intertwined with experiences of being in the world Where placed an expression of self and relations Terms like `my pills’ = statement of ownership / degree to which pills part of `us’ For chronically ill meds central to the self – provide a sense of certainty E.g of discussion in household of 4 young people.

IDENTITY AND CARE 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 Caring by giving medicines to others Reaffirm bonds between household members Expressed through affection, affiliation and humour. e.g household discussion about reminding each other to take their meds

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.”…

Meds interwoven into households Taking of meds taken for granted - like having a cup of tea Emplacement of meds reflects relationships and uncertainties of illness Meds bound up in relationships People transform pharmacological objects into social objects with histories and memories Meds central to reconstruction of home as space of care

Conclusion 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.