Thursday, November 25, 2010

How Commerce Reshapes Knowledge: Matheson on Pharma's Influence on Science

I recently read David Egilman and Emily Ardolino's well-done, comprehensive chapter in The Bottom Line or Public Health: Tactics Corporations Use to Influence Health and Health Policy, and What We Can Do to Counter Them. Via Egilman and Ardolino, my attention was called to a 2008 paper by Alastair Matheson, which is the main focus of this posting. (subscription required to access article) I found of interest both Matheson's message and where he's coming from.

Matheson (who's based somewhere in the UK) begins his essay, "Corporate Science and the Husbandry of Scientific and Medical Knowledge by the Pharmaceutical Industry," by stating that his research method is that of the informed insider writing about his own experiences, working for a decade in various roles within the pharmaceutical industry. He compares himself briefly with Michael Oldani, the former-drug-rep-turned-medical-anthropologist. But in one way the comparison is misleading. Oldani writes primarily as a convert; from the vantage point of his former Pharma colleagues, he's a turncoat. He now rejects the value system that guided his work when he was a rep. Matheson, by contrast, seems not to want to burn bridges with his former bosses. He writes as a moderate, someone trying to find the middle position between Pharma and its most severe critics. He regularly reminds us that in his opinion, Pharma does a lot of good with its research and adds considerably to the store of medical knowledge. A typical sentence is: "It is through convincing science, not conspicuous marketing, that pharma prefers to engineer commercially productive knowledge."

A cynical reaction to Matheson is that he's really a turncoat but for whatever reason wishes to cover his proverbial hind end, and so all this pro-industry language is really just a smoke screen. A more sympathetic reading is thatMatheson believes the good things that he says about the industry and its research. That is important because he also says a lot of highly critical things, and in the end offers a severe critique of the industry as it now functions. These criticisms might be ho-hum coming from pharmascolds like me, but cause us to sit up and take notice when emanating from someone both knowledgeable about the industry and also sympathetic to many of its aims.

Matheson's case on the industry is rather deep and theoretical. He's concerned about how medical knowledge is ultimately constructed, and argues that presently, the knowledge-construction business is influenced much more by industry marketing and profit-seeking behavior than anyone who takes the scientific truth-searching agenda seriously could be comfortable with:

"Pharma's influence within the overall dispositif of biomedical knowledge production is pervasive, reaching beyond research per se into the networks, institutions, cultures and mind-sets of academic medicine and scienc--though many within these communities may be but dimly aware of such influence. Pharma's contribution to medical-scientific knowledge is manifest on many levels, including the dominance of the biomechanistic model of human health, the choice of what problems are investigated, the drugs themselves and associated clinical and mechanistic research, and the way specific aspects of human biology, pathology and medicine are constructed.... From pharma's perspective, the trajectory of scientific knowledge may be partially contingent with respect to the possibilities human biology affords, but it is non-contingent with respect to market potential. [Some] have suggested that disease classification is driven increasingly by the reported effects of drugs, but a fuller statement would be that our conceptualization of drugs and diseases are adjusted each to the other, with human biology and market potential jointly arbitrating the negotiation..."

To spend just a minute unpacking a bit of this, let's take the claim that pharma's influence over medical knoweldge helps to drive and perpetuate "the biomechanistic model of human health." It's an article of faith among primary care physicians like me that this model, for all the great discoveries that it has generated through the 20th century, also has substantial weaknesses and may indeed be reaching the limits of its usefulness, especially in the US where it has fed out-of-control health costs. Within the confines of this model, it is very difficult to talk about personal responsibility for health, the importance of lifestyle change on health, or the importance of social and psychological variables in determining health and illness. Yet pharma's role in the construction of medical knowledge helps to assure, first, that this model continues to dominate thinking within the major medical institutions; and second, that pharma's role in promoting this model remains well concealed. If people (both physicians and the general public) came to believe widely in what the critics of this model say, then fewer people would be persuaded of what Pharma wants them to believe deep in their bones--that the shortest road to good health lies in swallowing a bunch of pills, the more expensive the better.

A couple of other choice quotes: "Systems by which KOLs [key opinion leaders, prominent physicians selected by drug companies to transmit their messages] are selected, positioned and used to exert influence are well established--indeed software for managing KOLs is commecially available." And: "Within the KOL caste there is structure and hierarchy, beginning with new blood and 'rising stars' and culminating with the grandees. KOLs considered sympathetic to a product are sometimes describes as 'friends'; those thought overly anxious to offer endorsement for rewards may be light-heartedly referred to as 'tarts'." (The addition of the phrase "light-heartedly" here, which challenges credulity, may tend to push one toward a more cynical reading of Matheson's pro-Pharma stance.)

Matheson ends by calling for creation of some sort of International Standard of Integrity in Science. He's a realist and knows that science will always be carried out in a social context, and that social context will help to determine what is seen as "truth" within science. Yet he also argues that as of now, the commercial pressures on that "truth" are simply too great for anyone who cares about science to accept.

Matheson A. Corporate science and the husbandry of scientific and medical knowledge by the pharmaceutical industry. BioSocieties 3:355-382, 2008.

Egilman D, Ardolino E. The pharmaceutical industry, disease industry: a prescription for illness and death. In: The Bottom Line or Public Health: Tactics Corporations Use to Influence Health and Health Policy, and What We Can Do to Counter Them, ed. Wiist WH. New York: Oxford University Press, 2010.


Joseph P. Arpaia, MD said...

One powerful driver of the emphasis on pharmaceuticals is the "need" for a placebo-controlled study.

Since pharmaceuticals are about the only intervention for which a placebo is possible, that "need" for a placebo control delegitimizes other types of interventions, especially social or educational interventions.

Furthermore the conflation of statistical significance with clinical significance encourages investigators to pursue lines of research which are clinically useless.

Nancy Wilson said...

Howard, here is a link to Alastair Matheson's article (no subscription required) via his website