Who Decides Who’s Sick?

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December 5, 2006
OnTheCommons.org

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Back when, Ralph Nader used to ask college audiences, “Who defines what a problem is in America today?” Who decides that tired hair, say, is a problem of epochal proportions, while the decimation of species and the befouling of the air flit only episodically across the public screen, rarely long enough to change behavior in any significant way?

Nader was talking about the ability of the marketing industry to channel thought in the direction of problems for which commodities appear to be an answer. Rightward polemicists scoff at the notion that advertising actually could influence an independent and free-thinking people. They don’t explain why corporate leaders, “rational decision makers” that they are, would devote over a quarter of a trillion dollars every year to this purpose anyway.

Besides, the real impact of marketing is less to sell particular products, than to keep us immersed in a product culture in which problems always are defined — and if necessary invented — in ways that lead to something to buy. Sell the problem, not the solution, the old huckster adage goes; and nowhere is this process more insidious than in regards to drugs. The drug industry now spends about as much inventing new diseases, and extending the boundaries of old ones, as it does devising its form of remedy for those.

A former CEO of Merck once wished aloud that he could make Merck like a chewing gum company. Then he could “sell to everyone,” he said. The way things are going he’ll soon have his wish. Ray Moynihan, author of Selling Sickness, has observed how drug companies have enlisted both doctors and patient advocacy groups in “defining more and more people as ill.” The official manual of the American Psychiatric Association now includes such things as “social phobia” (ie shyness), “identity disorder,” “conduct disorder,” “oppositional defiant disorder,” and “rumination order.” I wonder how they left out breathing.

Pretty much every bump in the road of a normal human existence has been redefined as pathology in need of what is called, in the wonderful euphemism of the trade, “pharmaceutical intervention.” Economists long have lectured us on how human wants are “infinite.” Now we know what they mean. Rarely has the central dynamic of the commercial culture they tout been on such egregious display.

This means more business for those docs — psychiatrists in particular — who claim this new territory as their own. They took an oath to heal disease, but they’ve ended up promoting it. (Many in the medical profession deplore these trends; but lacking the megaphone provided by drug industry dollars, their voices are not always heard.) But the main beneficiaries are pharmaceutical companies themselves, which, at the behest of the Invisible Hand, seek to find more reasons to call more of us sick.

The latest example is shortness of stature, a circumstance with which I myself am familiar. Some three decades after the Randy Newman song, the pharmaceutical industry has taken the cue, with an array of drugs to remedy the supposed disease of being of less than imposing height. Supposedly these drugs are aimed at the truly short, who comprise about 1.5% of the population. (That would include men something under five feet.)

But we are talking about people who are otherwise normal, in terms of growth hormone levels and every other way. They are simply short; and their disease, if disease it is, is a social condition, not a physiological one. As Business Week pointed out in a recent article on the subject, once the drugs are out there, the bar inevitably goes lower — or in this case, higher. Genentech now is marketing a drug called Nutropin for kids who are simply shorter than the mean, even if their own growth hormone levels are normal.

The magazine cites the case of a father in Florida who became “absolutely irate” at a prominent endocrinologist who wouldn’t prescribe a growth hormone for his son, who was projected to grow to 5’9″ without them. The father would most likely go shopping for more accommodating practitioner, and as the first doctor put it, “No doubt he’ll get someone to prescribe it.”

What is most interesting about the Business Week piece is the reasons parents gave for seeking the drugs. “I was worried society wouldn’t accept him,” one mother said of her son, who would have been just below five feet without the pharmaceutical boost. Such statements generally are taken as conclusive, yet they invite a host of questions. Exactly who and what is sick here? Is it the individual who is born short? Or is it the others — collectively called “society” — who get unhinged by shortness? Do we really need to live in fear of what society might or might not think of us?

Perhaps most important, does real progress lie in a pharmaceutical version of blaming the victim, through drugs to fix his or her supposed deficiencies? Or does progress lie in becoming big enough to accept that some people are different from ourselves, and thanks be for that?  “Society is buying into the idea that someone who’s short has a medical problem,” said the member of a Food and Drug Administration advisory panel who voted against approval of Eli Lilly and Co.’s growth hormone, Humatrope. “I’m real worried about the medicalization of shortness.”

Medicalization means turning more of life into occasions for the ingestion of a drug. It is an advanced form of re-engineering humans as “consumers” to fit the needs of a corporate market machinery that is running out of autherntic needs to fill. (Where such needs exist, as in the Third World, there is not money to pay, and therefore an absence of what economists call “effective demand.”) McGovern observes that the U.S. is the “epicenter” of such “disease mongering,” Though less that 5% of the world?s population, we account for half the world?s drug sales. Much of that is for conditions that wouldn’t even be considered diseases if the industry and its accomplices had not defined them as such.

The costs are large and growing. Growth drugs typically cost in the vicinity of $25,000 a year, according to Business Week. Much of that is paid by insurance, and thus cuts into the pool of funds that otherwise might be available for people with pressing health needs. No funding system under the sun — not single-payer or anything else — can keep up with a populace that uses high-priced drugs like chewing gum, as the industry desires.

But more important, the obsessive focus on medication chooses the proverbial pound of cure over the ounce of prevention. It takes both attention and resources away from public health, which is humanity’s best hope for dealing with much disease. This means, for example, vaccines and sanitation to subdue communicable diseases, and greater focus on prevention generally. It means stopping the disgorging of industrial poisons into the air and water, and encouraging a built environment that enables people to walk instead of drive.

Public would attack the stigmas on being different, rather than selling attempts to conform to an ignorant — and impossible — norm. It would eliminate the advertising of prescription drugs and encourage healthful living instead.

This is commons-based health policy. It starts with health rather than sickness, and with the habitat we share rather than with the needs of the industry that seeks to sell us cures. The drug industry has a place of course, but it should — and could — be healthfully less.

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