JOSEPH DUMIT AND NATHAN GREENSLIT
INFORMATED HEALTH AND ETHICAL IDENTITY MANAGEMENT (Editorial)
Culture, Medicine and Psychiatry 2006. DOI: 10.1007/s11013-006-9017-z
The scale of pharmaceuticals is almost unbelievable: trillions of pills consumed per year, 602 billion dollars in global sales, 3.6 billion prescriptions in the U.S. alone in 2005. The average insured American purchased thirteen different prescriptions last year (IMS 2006, CMS 2006, Express Scripts 2005). Add to this the diversity of industries involved in pills broadly speaking – prescription only, over-the-counter, contraceptive and repro- ductive, contract research organizations, supplements, and addiction – and the conceptual and research ability of anthropology is stretched to its limits. Industrialized medicine is now operating at an unprecedented scale, leading to a pervasive pharmaceuticalization of culture (a form of lifeworld colonization or medicalization from some perspectives) in which core metaphors of identity, health, illness, life, longevity, and relationships are mutated. We are also witness to a consumer-marketing transformation of medicine, in which the pharmaceutical industry has openly inserted itself into public debates about healthcare – for instance promoting direct-to-consumer (DTC) advertising as a legitimate form of medical education, in which persons are solicited as ‘‘patients-in-waiting’’—those who do not know they need pharmaceuticals until they encounter advertising for them (Dumit and Greenslit 2005). The articles in this issue, collected under the title of ‘‘Pharmaceutical Cultures,’’ offer new approaches to studying and theorizing these dramatic and pervasive cultural shifts brought about by pharmaceutically-centered medicine.
Collectively these articles represent a contribution to the growing number of pharmaceutical studies in anthropology. They are in conversation with the diverse critical literature on the pharmaceutical industry in the popular press (e.g., Angell 2004; Moynihan and Cassels 2005). They follow the first waves of medical anthropology of medicines, including western medicine (see review by van der Geest 1996; also Nichter and Vuckovic 1997; DelVecchio Good 1995; Illich, 1976), and are part of a new network of pharmaceutical studies located across anthropology, sociology, and science and technology studies (STS).1 At the intersection of these disciplines, new global-scale studies of pharmaceuticals document the deep, intricate relationships of national and international standards, research, practices, pills, diagnoses, and identities (Lakoff 2006; Petryna et al. 2006; Hayden 2003; Sunder Rajan 2006). As ethnographies, these analyses draw upon insights from STS including co-production, actor-network theory, and studies of standardization (see Sismondo 2004). At the same time, staying on the ground reveals local biologies (Lock 1993), local practices (Ginsburg and Rapp 1995; Biehl 1999), local measurements (Nelkin and Tancredi 1989), local diagnoses (Good 1994; Fortun 2001), local phenomenologies (Lee 1993; Martin 1987; Scheper-Hughes 1987; Csordas 1994; Becker 1995), and local drug reactions and uses (Lovell 2006)—all of which are subject to media, culture, social movements (Greenslit 2006; Lanzelius and Dumit 2006; Brown and Zavestoski 2001), and public relations and the social constructions of clinical trials (Epstein 1996; Petryna et al. 2006; Maurer 2005). These local aspects offer numerous gateways into the study of the pharmaceuticalization of culture, as ways to make the sheer scale of pharmaceuticals a more understandable anthropological phenomenon and a more tractable object of ethnographic inquiry.
Indeed, the scale of pharma may seem blinding, but unlike the blind men in the fable of the elephant, who each feel a different part of it and therefore experience a different creature because it is so big, these scholars have the advantage of knowing that they are working on the same unseeable object. The authors stay here in the U.S. in order to study the elephant horizontally across regimens that intersect in pharmaceutical cultures. Prescriptions, OTC, supplements, contraceptives and gambling may seem like diverse and separate topics, but within them are a series of interconnected themes. In this introduction, we want to highlight two aspects of pharmaceutical culture that are revealed in these studies. The first is the need to take into account the ‘infor- matization’ of health and the second is ethical identity management.
Informated health operates on two levels. First, the very notion of health and illness has become dependent on techniques of measure, especially mass clinical trials and epidemiology that provide statistical proof of disease rates and therapeutic effects. In locating where these measures become the only proof and indication of health and illness, we can see the contours of an emergent epistemology of informated health. Extending the work of histo- rians of medicine (Marks 1997, Reiser 1978, Greene 2004), David Healy has discussed the process in which both patients and doctors come to distrust their own senses in order to accept the microjudgments of trials and statistics. At the popular level, Mark Nichter and Jennifer Thompson show how people conceive of their health and future in terms of being ‘‘informed’’ with information. Even when this is individualized information, it still depends on a notion of a baseline of information ‘‘out there.’’
Dependency on information means that the apparatus of the production and dissemination of health information become sites of struggle. Facts become material forces in the double sense that users fight for the proper production of facts (e.g. about side effects, or the effectiveness of dietary supplements) and everyone fights over the dissemination of facts, over ‘‘controlling codes’’ in Melucci’s sense (Melucci 1996). Healy details the ways in which side-effects data are often kept private, so that guideline makers are technically making their decisions on the best ‘‘available’’ information while misleading themselves and everyone else about the safety of these drugs. Nichter and Thompson point to the equally important problem of how little information about supplement safety and effectiveness is available because it is never produced in the first place, due to supplements’ in-between federal status of being neither food nor drugs.
Dissemination also travels along culturally sanctioned lines of communi- cation. Thus Andrea Tone shows how attempts to culturally manage morality in the U.S. produced an underground contraceptive market that only appeared publicly in the form of euphemisms. Likewise, Healy describes how pharma companies get doctors to ‘‘privately’’ talk about what cannot be said publicly by the company. In this manner, they are able to disseminate authoritative statements about drugs without violating advertising regulations.
Emily Martin discusses how drug representatives both gather and dis- seminate information about their drugs through stories. This is an example of what Holmes and Marcus (2005) have called ‘‘para-ethnography,’’ where the representatives understand their world through the consideration of qualitative, anecdotal data, from which they extract generalizations about how the drugs work. In an inversion of the informatization of health, Martin explains how this process provides the representatives with thick descriptions of success stories that ground their ethical sense of helping others and in effect insulates them from the statistics which show the relative ineffectiveness or dangerous side-effects of many psychotropic drugs.
ETHICAL IDENTITY MANAGEMENT
Peter Kramer’s 1993 Listening to Prozac used the promises of new psy- chopharmaceuticals to stage in the increasing impossibility of distinguishing between being in control through drugs versus being out of control because one needs drugs. These papers show that in the subsequent thirteen years, ethical questions of control have come to assume pharmaceutical dependency as normal (Dumit 2005). Questions of identity, control, and risk are simply no longer formulated as choices for or against drugs in general, but are, rather, always questions of which drugs and in what combinations. Furthermore, the mind, brain, and mental illnesses themselves are understood as thoroughly pharmaceutical.
Thus Natasha Schull shows how gamblers distinguish between depen- dencies, accepting dependency itself as a given, and preferring to choose their dependency as opposed to not choosing it. Choice and therefore will and identity are materialized in how one manages one’s fundamental addictions. Gambling machines and Zoloft, for example, are made comparable through their shared ability to modulate intimacy in orgasms. Nichter and Thompson discover a related ‘‘pharmacological idiom’’ in which supplements are used to substitute for pharmaceuticals through comparable consumption. These formulations seem to echo Kramer’s summary efforts to put psychoanalysis and pharmaceuticals on a comparable plane of efficacy in treating mental illnesses, but they are taking the comparability for granted and self-talking within the ‘‘pharmacological idiom.’’
Identity in the U.S. then – one’s sense of oneself as a good, conscious, careful person – passes through both informated ‘‘objective self fashioning’’ (Dumit 2004), ‘‘pharmaceutical rationality’’ (Lakoff 2006) and the deeply social and symbolic meanings of pills themselves (Greenslit 2006). Americans are constantly asking themselves if they are doing the right things in order to be the good people they want to be, and they answer those questions with reference to how they ‘‘choose’’ to manage their drugs. Women manage their sexual independence and their sense of it through The Pill (Tone), patients manage their sense of carefulness through being informed and taking healthy supplements versus risky pharmaceuticals (Nichter and Thompson), gamblers manage their sense of rational control through modulating competing addictions (Schull), and the public in Healy’s accounts ultimately must become self-motivated through individualized information seeking against the information control of pharmaceutical companies. In all of these cases of choosing the right combinations, Americans are also ‘‘producing [their] identity through consumption’’ (Nichter and Thompson).
Finally, Martin and Healy both show that the management of corporate identity, at the company-wide level or at the level of the individual, takes the form of controlling the flows of information potentially available, creating ethical pockets within which the informed self is good despite being misinformed from a wider perspective. This lesson, in turn, rebounds on the ethically motivated health-oriented consumers of the other papers, who are, like all of us, faced with the field of facts as public relations.
1. One site for this network is the Pharmaceutical Studies SIG (special interest group) of the Society for Medical Anthropology (http://www.medanthro.net/ research/pharm/academic.html).
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