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Review Essay



Selling Sickness: How the World's Biggest Pharmaceutical Companies Are Turning Us All into Patients
by Ray Moynihan and Alan Cassels.
Nation Books, 2005.
Hardcover, 254 pages. $25.00

Selling Sickness video.
Directed by Catherine Scott.
Icarus Films, 2004.
Run Time: 52 minutes.
Closed Captioned.
Sale/video-dvd: $390
Rental/video: $75

Cal Montgomery says,
"Although the copy of the film Selling Sickness that I saw was uncaptioned (and would therefore have been inaccessible to me had I watched it in the settings in which it's meant to be shown), the distributor volunteered to me that captioned copies will be available."

Buying Sickness

A review by Cal Montgomery

This is the second in Cal Montgomery's 3-part series on Medicalization.

Read Essay 1:
Defining Autistic Lives.

Read Essay 3:
The Way Things Are.

One of the final straws in my changing hospital systems for pain management was when my doctor told me to start taking 100 mg. of Celebrex up to twice a day. A year before, she'd had me on 200 mg. once a day. It had no noticeable effect, and we had agreed that I would stop taking it. When I tried to suggest that putting me back on it wouldn't address my pain and might cause side effects, she assured me that the drug was safe enough that I shouldn't worry that the potential downsides for me outweighed the likely upsides for me. (All drugs have risks; you've got to balance the likelihood and severity of the side effects against the likelihood and value of the therapeutic effects when deciding whether or not to take a medicine.)

The next day, the media was full of stories about the dangers of Celebrex, and although those dangers appeared to affect people taking much higher doses than I was, I decided it was time to find a new doctor.

I've been watching commercials on TV, and I've learned that pharmaceutical companies are in the business of philanthropy. They only charge high prices for their drugs in order to fund research so that they can help more people; and they still find ways to make drugs available to the deserving poor.

If the pharmaceutical business is a philanthropy, are the beneficiaries the executives?

It's sort of like the way Philip Morris recognized that kids are absolutely desperate to get their hands on cigarettes. So they set up a program to help checkout clerks stand up to the onslaught of hopeful underage smokers. I learned that from watching commercials too.

But there's reason to suspect that in our capitalist society, philanthropy isn't the only reason to get into the pharmaceutical business. Look at the drug prices in Canada, with single-payer health insurance and the power to resist high prices, and then look back at what we in the U. S. pay for the same drugs. There's profit to be made.

The film Selling Sickness, researched and written by Catherine Scott and Ray Moynihan, is the sort of thing you'd expect to watch and discuss in a classroom or at a conference. It's just under an hour long, and it makes a lot of points in that time.

The book Selling Sickness (written by Ray Moynihan and Alan Cassels) is a nonfiction book aimed at a general audience pitched at about the level of Joseph Shapiro's No Pity.

Both explore the ways that society's reliance on prescription drugs is sustained and broadened by pharmaceutical companies seeking to increase profits. Both take as starting points the idea that there are real physical and mental illnesses for which powerful and even risky drugs may be worth it, but they argue that the pharmaceutical companies are doing us a disservice as they sell sicknesses and the drugs to treat them.

If the pharmaceutical business is a philanthropic one, then a significant number of the beneficiaries are executives, stockholders, advertisers, and medical researchers, and a number of patients aren't getting much benefit at all.

How was it that my ex-doctor thought Celebrex was so safe as to be worth taking even with no expectation that it would be of any benefit? How was it that she kept coming back to exactly that drug and no other, even though she rarely seemed to have reviewed my file before appointments?

I don't know, obviously; but there's a decent chance that she's been exposed to advertising. She might have been exposed directly by drug company representatives, by ads in professional journals, or by research paid for by Pfizer (which makes Celebrex). She might have been exposed or indirectly, with patients to whom the drug has been marketed asking for Celebrex by name. That advertising, say Moynihan and Cassels, is effective.

I figure that it worked for some of her other patients too, and for patients of other people she knows and respects, and that she has become accustomed to thinking of it as an effective non-narcotic option for pain. She was probably in the habit, by the time I met her, of jumping from "This patient is talking about chronic pain" to "and I should prescribe Celebrex" pretty quickly.

I'm seeing someone else for pain management now, and while I'm still in pain all the time, it's rarely so bad that I cannot read or write. Despite the number of commercials I see informing me that nothing less than being totally pain-free is acceptable, and despite my curiosity about what pain-free feels like, I've achieved the goal I set in 1999, and I'm very happy about it. Without Celebrex, and with side effects that I think are acceptable given the way the drugs improve my life.

The lively film Selling Sickness is focused on selective serotonin reuptake inhibitors (SSRIs) like Zoloft, Paxil, and Prozac, and the ways in which they and the conditions for which they are approved are marketed by drug companies.

Like Shapiro in No Pity, authors Moynihan and Cassels in their book Selling Sickness tell one story per chapter, knowing that the larger pattern will eventually become clear to readers. And like Shapiro they spread their stories out broadly. You will read about premenstrual dysphoric disorder in Selling Sickness, but you will also read about high cholesterol.

Neither the book nor the film is an attempt to suggest that all people with a particular diagnosis or set of diagnoses are just blowing things out of proportion. Rather, they argue that while prescription drugs can be used in ways that clearly benefit patients who need some kind of medical intervention, they are marketed in ways that encourage their use in ways that help very little (if at all) without respect for the real and often serious risks. Not only are some people who could benefit a lot from certain drugs not getting them, but other people are taking powerful and potentially dangerous drugs despite getting very little benefit from them.

Moreover, Moynihan and Cassels argue that the same marketing is encouraging us to think of more and more of our lives as pathological, and that much of the health information we get is distorted so that drugs are the first thing we think of when we worry about attention deficit disorder or high blood pressure, even if there are other, safer, things that we could do that would benefit us more.

The basic idea common to both film and book should be familiar to anyone who's read John McKnight's "John Deere and the Bereavement Counselor," available in his book The Careless Society: Community and its Counterfeits, though in that essay it was professionals under the microscope and in both Selling Sicknesses it's drug companies. In all three cases, though, I learned a lot: I'd never heard of "condition branding" nor understood the ways in which physicians' continuing education programs help promote specific sales goals. Until I came across the Selling Sickness book and video, I hadn't fully grasped, either, the ways that people are distracted from treatments by advertising that hammers home a message of drugs, drugs, drugs.

I don't think you have to know anything about medicine or chemistry or psychology or marketing to be able to understand what Moynihan, Scott, and Cassels are getting at and to be able to see the connections between what they're writing about and your own life. I certainly didn't, and I think that's one of the strongest features of both film and book.

How effective is the drug companies' marketing, and how does it work?

Moynihan and Cassels undercut themselves a bit on the advertising, seeming to argue that doctors' prescribing habits do not change because of advertising. I think they mean to say that doctors do not deliberately change their habits for any reason other than that they think they're improving the treatment they can offer patients. I think they mean to say that some of the correlation between exposure to advertising and prescribing habits may be because doctors who like pharmaceutical treatments seek out the sort of information that the ads convey.

Think about it: I'm much more likely to buy a book I've looked up on Amazon than one I haven't, but that's mostly because I plug every title I'm considering buying into the Amazon search feature to see what comes up. Amazon's "recommendations" for me are hilarious rather than helpful.

I'm quite willing to believe that doctors prescribe medications they think are likely to work and have tolerable side effects, and not because some company has treated them well. For that matter, it seems to me quite likely that many of the people who work at the big drug companies believe that what they're doing is primarily philanthropic. But that doesn't mean that there isn't something else going on. Many of us don't think we make our choices in the supermarket because of advertising either, but if the people who make and package foods didn't have a good reason to think we do they wouldn't be spending all that money getting their ads out.

In "Defining Autistic Lives," I pointed out that disabled people are disadvantaged within society and that that disadvantage is believed by most members of that society to be a natural consequence of individual physical and mental deficits which are properly considered medical problems.

The reason that I'm focusing on that fact about disability is simple: it highlights the way that early 21st century Americans think about disability, and in particular the way that they believe disability comes about and functions to disadvantage us. Disability is something we have -- "I have autism," says filmmaker Sue Rubin -- as individuals, and in a society that likes to think of itself as meritocratic we often believe that our proper places in society are determined by our ability and our effort. "Supercrips" and other disabled parvenus who manage, by dint of effort, to overcome their inherent lack of ability and so achieve good places in society remind us that all those disabled people who don't manage to do the same have the opportunity if only they'll put forth the effort.

It's a helpful reminder, because it allows people to feel superior about their egalitarianism while ignoring the disadvantages they help impose on people they believe to be their inferiors.

But at the same time, I am trying to highlight the ways in which people committed to disability rights need to confront medicalization -- the way that society comes to understand some kinds of disadvantages as medically caused. We need to confront medicalization's role in justifying both our failure to achieve like nondisabled people and our need for affirmative barrier removal on the one hand. We also need to confront medicalization's role in suggesting to a society that believes medicine reveals that some ablist patterns of disadvantage are the way things should be.

While I watched and read what Scott, Moynihan and Cassels had to say, I was reminded of a model of medicalization that Peter Conrad and Joseph W. Schneider gave in their book Deviance and Medicalization: From Badness to Sickness.

They began with deviant behavior already being treated as bad.

Disabled people can be deviant in a variety of ways. We sometimes fail to behave in ways that we are expected to -- making eye contact, responding "appropriately" to sights, sounds, and touch, learning to walk and talk -- and our failure to meet these expectations is considered a bad thing. We also sometimes behave in ways that we are not expected to -- headbanging, insisting on gestural communication, continuing to move around our houses on our stomachs well into childhood -- and these behaviors are also considered to be bad.

When Sue Rubin writes that those people who oppose autism cures are "a variation of the norm" and "could pass for normal," she's arguing that these people weren't truly (or involuntarily) deviant in the first place and that our deviance, unlike hers, should not be medicalized, and I believe that Scott, Moynihan, and Cassels are making the same point about many of the people being targeted by drug company advertising.

Conrad and Schneider wrote that the next step was "prospecting" or "discovering" a medical cause of or medical treatment for the deviant behavior. In their discussions of "condition branding" and their presentation of very common problems (like having trouble with a shopping cart) as possible signs of serious disorders, Scott, Moynihan, and Cassels are talking about companies deliberately identifying certain behaviors and "risks" as medically deviant in order to profit from a "sufferer's " demand for drugs to control the deviance.

The cases put forward in the Selling Sickness book and video include "condition branding" -- the identification of a new "disorder" or "risk factor" that may have not previously been seen as deviant, and then selling it as a medical problem in need of a pharmaceutical solution. Not just "a pill for every ill," as Scott, Moynihan, and Cassels put it, but "an ill for every pill."

The third step, according to Conrad and Schneider, is "claims-making":

This is a key stage in the emergence of new deviance designations. It is at this point that champions, moral entrepreneurs, and organized interests begin actively to make claims [that the behavior is medical in nature] and attempt to expand the medical social control turf. Both medical and nonmedical interests engage in claims-making activities.

Claims that this or that is or is not "a disability" are something we're all familiar with. To file an ADA lawsuit, you've got to demonstrate that you are, in fact, a person with a disability, and ADA defendants are doing well these days arguing that the plaintiffs are nondisabled.

Some older people insist that they do not have disabilities and as proof refuse to use any of the traditional tools of disability despite their friends' and families' urging. I have claimed disability status since my time behind locked doors; before that my parents strenuously denied on my behalf that I was disabled.

Some disabled people want to have a broad definition of "disabled" because if there are a lot of us then maybe we'll have power, whereas others want a narrow definition because if there are a lot of us then there may be "backlash" from people and organizations that don't want to accommodate very many people.

The very same person or organization may use conflicting definitions of "person with a disability" at different times. Centers for independent living (CILs) in my state jumped on the federal government's claim that 20 percent of Americans are disabled, and started insisting that they should get funding based on that figure ... at the same time that at least one CIL was only counting time spent with "visibly disabled" people toward each employee's expected number of consumer contacts.

It's good for pharmaceutical companies if they can convince a whole lot of people that they're sick.

At the same time parents may want their children in the special education system or out of it; special education teachers and disability professionals may want the status that goes with being an "expert" about a large group; the people at the Social Security Administration may want there to be as few disabled people as possible; and so on and so on and so on.

In exactly the same way, pharmaceutical companies have an interest in a whole lot of people being sick with exactly the conditions for which their drugs are approved, while health insurance companies have an interest in a very small number of sick people.

There is tremendous significance to claiming disabled status, and there are all sorts of reasons that have nothing to do with finding out the truth that may influence decisions about who is and who is not disabled.

In Conrad's and Schneider's fourth stage of medicalization is "legitimacy." This is when various individuals and groups pursue an official recognition of the medical viewpoint.

When, for example, we work to pass laws that describe disabled people's substantial limitations as being the consequences of our individual physical or mental impairments rather than the consequences of an unjust social arrangements, we're legitimizing the medical model of disability. When disability services providers require us to provide medical documentation that we qualify for barrier removal, they're legitimizing the medical model of disability. And when pharmaceutical companies get the Food and Drug Administration to sign off on the appropriateness of their products for a new group of people, they're legitimizing the medical model of the traits and behaviors common to that group.

The fifth and final stage is institutionalization, in which the medical explanation "reaches a state of fixedness and semipermanence." It's legitimate. It's "codified" by becoming "an accepted part of the official and/or legal classification system" or "bureaucratized" by being built into large social control organizations.

I believe -- as I tried to indicate in "Defining Autistic Lives" and earlier in this piece -- that one important feature of disability is that it has an institutionalized explanation: physical or mental impairment.

In this way ablism is different from racism and gender discrimination today, but looking at the history of the struggles against racism and gender discrimination, it's clear that at one time many people took it wholly for granted that that discrimination was justified because members of the disadvantaged group were biologically inferior to male WASPs. Systems that are generally acknowledged now to be unjust have in the past been considered not only perfectly just, but in fact natural and even good ablist systems continue to be considered natural and good in the U. S, today.

I would recommend both Selling Sicknesses to people interested in thinking seriously about the ways in which we come to see certain things as sicknesses. They are pitched for general audiences with no special training, and I found myself enjoying them both.

The film is significantly superior to the book for getting a sense of the advertising directed to patients. TV ads are used in the film, whereas they are -- naturally -- only described in the book. It's also something a group could read and discuss in one meeting. The book, however, provides a much wider perspective on the range of methods that pharmaceutical companies use and what the consequences of those methods are; it would work better for independent study or, since it's a relatively quick read, as something members of a group read before getting together to talk about it.

Posted 7/28/2005

Cal Montgomery writes for Ragged Edge. Although she got a free copy of the book and a loaner of the video she is reviewing here, that's the extent of her financial interest in any company that stands to benefit from this review.

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