Editorial Note: It’s common to find those behind Global Mental Health say that they might not originally have believed in the reality of mental illness and the efficacy of treatment but they do now. This and two following position pieces don’t come from the same conversion perspective. I have always believed in the reality of mental illness and the efficacy of treatment. Nevertheless the enthusiasm of the converts is worrying.
This piece first appeared as a review of a recent book Pharmaceutical Selves, which has the subtitle, The Global Shaping of Experience in an Age of Psychopharmacology. The review appeared in Transcultural Psychiatry.
‘Pharmaceutical Selves’ has a distinguished authorship line – Ecks, Biehl, Good, Jenkins, Luhrmann, Martin, Metzyl and Saris. The title Pharmaceutical Selves conveys both the fact that the group of drugs under consideration are the psychotropic drugs and that globalization poses a set of paradoxes. The subtitle was almost redundant – except that it points to areas on which there are strains between the authors. Is there a global shaping of experience they ask? Is there a pharmaceutical industry hegemony?
Let’s sort out Indonesia
The tensions come to their clearest focus in Byron Good’s chapter where facing a series of disasters in Indonesia he critiques standard views of the hegemony of Western pharmaceutical companies and bemoans the lack of resources including psychotropic drugs available to Indonesian sufferers from nervous disorders. Should anthropologists be standing in the way of the pharmaceutical juggernaut, he asks, or should they be ensuring it can make its way down the remotest dirt tracks to the farthest flung outpost? Little time here for talk of outposts of Empire.
He cites a series of clinical cases to illustrate his points and summarizes what he has seen in the following terms: “There are few aggressive efforts to try different drugs or different dosages or to find a medication or combination of medications that will lead to real remission of the psychosis… Failures of response to medication then reinforce the view that drugs only treat superficial symptoms and not the essence of the sickness. Why have anthropologists become activists when it comes to detecting and treating HIV-AIDs but take quite the opposite approach to mental illness?”
Indonesian patients will unquestionably want life saving Western medicines just like the average North Korean would probably trade a lot for decent Western food. Indonesian patients would probably also opt for the latest Western psychotropics just as many in the Soviet bloc once coveted Levi jeans – if they had surplus disposable income. But wanting psychotropics and Levi jeans is a very different matter to needing life-saving medicines and food.
It seems that Good has bought whatever it is about the Western superstructure that generates wants of this sort. He seems to endorse company views that the latest drugs – which are demonstrably inferior to and vastly more expensive than older products – are in fact superior and do more than “treat superficial symptoms”. The skeptical attitudes of patients that he bemoans are ones that I offer as the orthodox views about what these drugs do in a series of my publications and have done in public lectures without anyone objecting. The same views could be found in most standard textbooks – until recently.
There are good reasons why the latest psychotropics don’t travel in the way the anti-retrovirals do. Indonesian patients and doctors I would say make the right calls – better calls than American patients and doctors. The question is why there is no hint from Good that this might be the case, and almost no analysis elsewhere in the book from the other authors as to why this should be.
While there is some mention of sponsored medical education and ghostwritten articles, there is nothing on how the market is structured so that even sophisticated academics can end up believing brain toxins are brain tonics, or that drugs such as the antidepressants labeled as causing birth defects nevertheless should be given to pregnant women in ever increasing amounts.
How do industry do it?
How has the pharmaceutical industry been able to recruit the most radical of feminists to do its marketing for it – with even the Boston Women’s Collaborative now among the promoters of antidepressants to women of child-bearing years? Probably exactly how they have been able to hide what they are doing from the authors of Pharmaceutical Selves. Until recently authors like these were precisely the people we depended on to work out what was going on in situations like this. How has this anthropological agnosia been brought about?
The original academic view of antipsychotics is that they were tranquilizers – they treat symptoms. Available over the counter, they would still be viewed that way by patients. It is doubtful if the benefits of any later antipsychotics would have led to their take-up in the West if it was patients doing the choosing. The huge doses of medicines advocated by Byron Good would have been inconceivable if patients bought these “goods” – with overall probably greater benefit to patients.
It would have been relatively easy for single universities or hospitals on their own to run controlled trials of the antipsychotics or SSRIs to explore their immediate tranquilizing properties – trials that would have differentiated them unequivocally from placebos – something that multi-centered company trials of these drugs as antipsychotics or antidepressants has failed to do.
Allied to issues like this are the status of these drugs on prescription only. This has put some of the most naïve consumers on earth – doctors – in the sights of the most sophisticated marketing machinery ever seen. Mixing Lord of the Rings metaphors with The Iliad, these same doctors, under siege from industry, faced with a horse left outside the gates of the citadel have happily hauled it inside – oblivious to the fact that the most enthusiastic advocates of evidence based medicine these days are pharmaceutical companies. It’s one thing for Trojans under siege to be fooled, but why are anthropologists, bio-ethicists and others taken in?
Where are the anthropologists & social scientists gone when we need them?
There is no analysis here of structural factors like the prescription only status of drugs, the role of controlled trials as a marketing tool, or the patent status of drugs that makes Indonesia a potential market for Western pharmaceutical companies. The drugs are treated like simple facts, stripped of the social matrix that makes them drugs. It seems assumed they are born in the laboratory as drugs rather than chemicals.
There is much that is excellent about this book. A lot that is downright alarming. But also a big hole. Someone has to get to grips with how pharma do it. This was once the domain of medical anthropology and social science. But even the critics now seem to be defanged and are likely to be found endorsing the feeding of psychotropic drugs to pregnant women, infants, and Indonesians.