My mother is a psychiatrist, and I grew up in a house littered with Prozac pens and paperweights. By the time I reached adolescence, I had already attended my fair share of drug company-sponsored dinners and had met several fresh-faced, cheery pharmaceutical sales representatives who visited the outpatient clinic where my mother worked. The sales reps were part of the clinical scenery, bearing gifts of drug samples she could pass on to patients who couldn’t afford their meds. It seemed straightforward enough at the time.
Of course, ensuing decades have proven that the social and biological relations between pharmaceuticals, physicians, and patients are anything but straightforward. It is in these tangled relations that editors Sergio Sismondo and Jeremy A. Greene find their point of departure for The Pharmaceutical Studies Reader. Citing the value of a science and technology studies (STS) approach, Sismondo and Greene argue for a critical gaze on “the scientific, organizational, and rhetorical work” that engenders new logics and practices involving pharmaceuticals (p. 2). The seventeen previously published articles and book chapters that comprise the reader shed light on the complexities therein.
In their introduction, Sismondo and Greene invoke Derrida’s pharmakon to describe the pharmaceutical’s potential both to cure and to poison. It is not the pill or capsule that proves the focal point of this volume, however, but the social processes that undergird the production and marketing of drugs. Eleven of the articles address some aspect of pharmaceutical marketing, testifying to the wealth of strategies companies use to peddle their wares to unsuspecting customers. (Adriane Fugh-Berman and Shahram Ahari’s description of sales representatives’ “tactics for manipulating physicians” is particularly troubling when I think back on those fresh-faced, cheery reps who once frequented my mother’s office.) As these articles make clear, every interaction we have with pharmaceuticals is carefully framed, scripted, and finessed to ensure maximum persuasion to prescribe (for physicians) or request (for patients) a certain drug.
Sismondo and Greene have divided the book into five parts that represent cross-cutting themes in pharmaceutical studies: 1) pharmaceutical lives; 2) new drugs, diseases, and identities; 3) drugs and the circulation of medical knowledge; 4) political and moral economies of pharmaceutical research; and 5) intellectual property in global and local markets. In what follows, I highlight some of the articles that comprise each section.
Part I (Pharmaceutical Lives) provides a general overview of some of the people and processes involved in the pharmaceutical world. The first article (ch. 2), by Simon J. Williams, Paul Martin, and Jonathan Gabe, argues for the theoretical utility of “pharmaceuticalization” as a framework for understanding both the therapeutic and non-therapeutic roles of drugs in everyday lives. Pharmaceuticalization expands on the twentieth-century concept of “medicalization” by acknowledging that biological and psychological states are now targets of enhancement and transformation, not simply pathologization.
Part II (New Drugs, Diseases, and Identities) addresses the market logics that contribute to the creation of disease and identity categories, particularly vis-à-vis gender and race. Nathan Greenslit (ch. 4) details the rebranding of Prozac (fluoxetine hydrochloride) as Sarafem, a chemically identical yet symbolically separate substance. While the green-and-white Prozac pill was marketed as a treatment for depression, pink-and-purple Sarafem was advertised to treat premenstrual dysphoric disorder, itself a contested diagnosis. Greenslit demonstrates that “identity practices”—the situating of individuals and organizations with respect to sociomedical discourses—apply to pharmaceutical objects, as well, and are made manifest through direct-to-consumer advertising. Anne Pollock (ch. 6) recounts the “contingent history” of BiDil, approved by the Food and Drug Administration in 2005 to treat heart failure in “self-identified black patients.” Pollock unpacks the various actors and motivations that drove the production of this highly publicized yet commercially unsuccessful drug, arguing that its potency lies in its unresolvable “undecidabilities” as pharmakon (cure and poison) and as a material object rife with symbolic meaning.
Part III (Drugs and the Circulation of Medical Knowledge) offers explicit delineation of the marketing strategies employed by pharmaceutical companies. As mentioned above, Fugh-Berman and Ahari, the latter a former Eli Lilly sales rep (ch. 8), describe in chilling detail the strategies behind sales representatives’ social interactions with physicians, all of which are calculated to increase physicians’ prescriptions of their respective pharmaceuticals. Sergio Sismondo (ch. 10) introduces readers to a new set of marketing specialists (although they would rankle at such a description): publication planners who “ghost manage” the production of drug company-favorable manuscripts for publication in peer-reviewed scientific journals. He argues that publication planning represents a “new, corporatized, mode of scientific research” (p. 151)—research that is still scientifically defensible but is produced for the sake of the corporation. Scientific knowledge itself becomes a commodity to be bought and sold through knowledge brokers such as publication planners, medical science writers, and journal editors.
Part IV (Political and Moral Economies of Pharmaceutical Research) departs from previous sections in its attention to the material and symbolic construction of pharmaceuticals before they become marketable to the general public. This construction happens in part through clinical trials, and the need for participants for such trials gives rise to new populations of human subjects, whose rights are often protected in name only. Jill Fisher (ch. 13), Adriana Petryna (ch. 14), and Kaushik Sunder Rajan (ch. 15) all interrogate the slippery ethical standards of the American contract research organizations (CROs) responsible for conducting trials both domestically and abroad. Sunder Rajan describes the creation of a new infrastructure in India to support the mass migration of clinical trials, arguing that these trials have the potential to create two types of subjects: ethical subjects (i.e., researchers) and local experimental subjects who become exploitable human capital.
Part V (Intellectual Property in Global and Local Markets) returns to the idea of markets, this time linking patents, the generics industry, and public and private health organizations to explore the pharmaceutical landscapes of Brazil, India, and Mexico. Maurice Cassier and Marilena Correa (ch. 16) detail the “technological learning process” that occurred in Brazilian generics laboratories following the implementation of the Health Ministry’s 1996 policy to provide its citizens with universal access to HIV/AIDS drugs. Stefan Ecks (ch. 17) reveals how Novartis’s Glivec International Patient Assistance Program (GIPAP), which gave Indian patients the cancer drug Glivec free of charge, was driven not by corporate responsibility and the moral obligation to be a good corporate citizen, but rather by a strategy to protect Glivec’s high price point in American and European markets. Cori Hayden’s article (ch. 18) on the shifting semiotic terrain of “similars, generics, and interchangeable generics” (p. 262) in Mexico raises the question “of what, precisely, does a pharmaceutical consist?” (p. 264)—a fitting question to which each article in the reader offers its own unique answer.
The Pharmaceutical Studies Reader is the first volume to come out from the Blackwell Readers in Anthropology series in which neither of the two editors is an anthropologist. Sismondo is a philosopher by training, and Greene is a physician and medical historian. As the title of the book suggests, and as the authors make clear in their introduction, this is a volume situated within the interdisciplinary space of STS rather than in sociocultural anthropology proper. Articles focus on processes rather than people and engage with abstract concepts like regimes (“pharmaceutical,” “global scientific,” and “experimental,” to name a few) rather than lived experiences. The result is a portrayal of a Big Pharma behemoth that is well-nigh unstoppable in today’s neoliberal, global economy.
I do not intend to rehash the stale anthropological debate about structure versus agency, but agency is something we see little of when the unit of analysis remains at the level of regimes (pharmaceutical or otherwise) and multinational corporations. Sociologist Jill Fisher observes in her chapter that the failure of current models of informed consent to protect patients’ rights hinges on a crucial oversight in “focusing on how subjects participate but ignoring why” (p. 205). Her observation may as well have been about this reader; there is a lot of how here, but not a lot of why. Or rather, the uncritical assumption is that the why is always the profit motive—and while that may indeed be (and probably is) the case for the corporation, I think the editors missed something by not including literature that delves into the lived experiences of the scientists, physicians, patients, and other actors who constitute the heterogeneous pharmaceutical landscape. As Sismondo and Greene write in their introduction, “Drugs take on value because they simultaneously alter the chemistry and biology of our bodies, the expectations and categorizations of our experiences, and the potentialities and networks of our social relations” (p. 1). None of the articles explore these intimate processes, however, and I think the collection would have benefited from more engagement with the micro-social in addition to the macro-social.
Even the most comprehensive of anthologies cannot cover everything, and such critiques are not meant to detract from the strength of the conceptual and theoretical work included in The Pharmaceutical Studies Reader. In the brief foreword to Part II, Sismondo and Greene paraphrase Claude Lévi-Strauss by identifying pharmaceuticals as good to think with. So, too, are the articles in this volume. Taken together, they provide an in-depth look at the machinery that enables the continued expansion of pharmaceutical products, markets, and subjects.
Ellen Rubinstein is an anthropologist and Postdoctoral Fellow in the Department of Family Medicine and Community Health at Rutgers Robert Wood Johnson Medical School. Her research explores caregivers’ conceptualizations of mental illness in the U.S. and Japan.