Sunday, November 28, 2010

How Pharma Shapes Knowledge: Alastair Matheson Responds

In hopes of soliciting a few words of helpful commentary, I shot an e-mail to Alastair Matheson, the author of the article in BioSocieties profiled in the previous post. I did a lot better than expected and received quite promptly an extensive reply--so extensive that rather than relegate it to comments at the bottom, I thought it deserved its own posting. So here goes, and thanks to Alastair for favoring us with his further thoughts:

I’m delighted you saw fit to read and comment on my BioSocieties article. It’s a thought-provoking commentary and raises several points for me to respond to.

First, I should acknowledge that I am dependent on pharma for about half my income. I wish things were different – I would love to work in a university, or even simply to have university affiliation to put on publications – but this is the reality I am currently stuck with. My financial dependency did not make me hold back when I wrote the article, but my working relationships did mean I had to take confidentiality clauses and sundry other legal issues into account.

As for why I had some good things to say about pharma, the reason was simple: I wanted to be objective. Pharma does do some good, and in my experience employs largely decent people. Basic biological research conducted by pharma has helped elucidate numerous cellular and physiological mechanisms. Pharma may have produced a truck-load of mediocre, over-hyped drugs, but it has produced a truck-load of good ones too. I expect every last firebrand critic will gulp, inject or infuse pharma’s wares into their bodies at some stage in order to keep well or keep living. Any fair-minded analysis of pharma should acknowledge these truths – but most of all, an analysis like mine should do so, given its concern with standards of truth and truthfulness. If I am going to criticise pharma for bias, I must be unbiased myself. Ergo, if the application of the term "tarts" to some doctors was light-hearted (and it was), then I should say so.

But if we grant that pharma employs decent people and does useful work, how then can it be that it also does bad? Here we get to the nub of things, but I will confine my remarks to a couple of points.

First up: when we say that pharma does this or does that, what do we actually mean? Who exactly are we pointing the finger at? Although I wouldn’t place Howard in this category, I do get the feeling that some of pharma’s more boisterous critics watched too many Hollywood movies when they were growing up. Because if we really want to understand what is unwholesome about pharma, the first thing we have to do is ditch the idea that it is controlled by Darth Vader.

There is no Dark Lord or secret cult pulling the levers. What we have instead goes beyond the control of any individual - a mass of research, development and marketing programs, meetings, strategies, agendas, organizational relationships, personal motives and compromises, operating on numerous levels, both inside the pharma corporations and its satellite industries, and with respect to pharma’s external engagements. The ultimate driving force is of course profit and money is the lubricant, but the system as a whole is hugely diverse, dynamic and robust, and is shaped not only by strategic planning but by the continual selection and replication, in a Darwinian sense, of commercially successful strategies.

That is the type of entity we are dealing with. Now, with regard to the question of why pharma has an unwholesome side, you’ll have to read my article, although the root of the problem is of course money. To return to Howard’s commentary, however, the point I wish to make here is that one of the most insidious and troubling things about pharma is the way it infiltrates cultures, practices and discourses. It weaves itself seamlessly into them, then subtly transforms and regulates them in such a way that it becomes reasonable within the terms of the parasitized discourse to use pharma products. My own work has examined the way pharma penetrates and transforms the discourses and practices of medicine and science to make the use of drugs seem reasonable, undermining in the process the very values of truth and truthfulness that should set science apart.

Therefore, my contention that pharma does a lot of good science, and has lots of decent people working within it, has more about it than meets the eye. It is precisely because pharma does some decent science, and employs or co-opts many decent scientists and medics, that it is able to permeate science and medicine as effectively as it does. Like some subtle pathogen, it is exactly because it adopts the characteristics of the host that it is able to get into the marrow.

Indeed, one of the phrases I used and which Howard cites - "It is through convincing science, not conspicuous marketing, that pharma prefers to engineer commercially productive knowledge "- is not, in fact, a ringing endorsement of pharma, but an observation with a degree of ambiguity and irony about it.

Finally on this subject, I would like to comment on Howard’s suggestion that pharma’s “just-take-the-pill” ethos undermines personal responsibility for health. Maybe that’s true, but if so it’s only part of the picture. When one sees the efforts pharma puts into television advertising and direct-to-consumer disease mongering, what we are witnessing is not the destruction of personal responsibility, but rather its invasion and transformation, such that it is reconfigured and amplified in a way that drives increased sales of drugs. Pharma penetrates, manipulates and feeds upon the personal health anxieties of consumer culture in a fashion analogous to the way it penetrates, manipulates and feeds upon the professional cultures of science and medicine.

I don’t think my critique of pharma is trying to find some kind of middle ground or meet pharma halfway. On the contrary, I think it’s one of the most telling critiques around, because it tries to get right inside how pharma actually works.

Howard, thanks again for your excellent commentary on my paper, and for giving me the opportunity to contribute a reply!


Bruce Wilson said...

Thanks for posting this correspondence, Howard. Matheson states so well what many of us medical writers experience. We know there are serious problems with industry; many of us would rather be working for non-industry clients but opportunities are limited and the pay is much lower.

So we wend ourselves through the ethical minefield, avoiding the worst projects, and educating our clients as best we can without offending them and getting fired. We like working with decent people who value science, ethics, and medical integrity and we hate working with people who try to inject marketing messages into our work, no matter how subtle and how couched in scientific lingo. And as Matheson points out, it can be very, very subtle.

I hope others read this post and realize that not all medical writers are sad, sorry puppets of industry, ghosting our way through life at the behest of our industry clients. Quite the contrary. Many of us push hard to clean up medical communications and encourage our colleagues and clients to do the same.

Matheson's brilliant analysis of corporate-driven science illustrates well the limitations we work within. As an insider, he paints a far more accurate picture of the situation than academics who depict us the equivalent of Mafia "hit men," doing what we are told at the behest of our clients.

Thanks again for posting this. This is exactly the thoughtful discourse we need, not more mud slinging and stereotypes.

Bruce Wilson
Montreal, Canada

Alastair Matheson said...

I’d like to thank Bruce for his generous words about my article! However, I feel compelled to point out that the paper cannot possibly be construed as a vindication of medical writing. Apart from anything else, the paper is not about medical writing. It is about the interaction between commerce and the discourses, practices and knowledge bases of science and medicine.

Having worked on occasion as a medical writer myself, my personal opinion of the profession is not a good one. Most medical writers I have met are decent, hard-working and intelligent, but to the degree that they are called upon by pharma to bend or spin science in order to hawk drugs – and let’s be honest, most medical writers are required to do just that – to that degree, medical writing is in my opinion a sad, servile, bottom-feeding profession. I think a lot of people drift into it because they don’t have any better options, and need to pay the bills.

Bruce has a different impression of medical writing, which I respect, and I admire his constructive engagement with the ethical challenges this kind of work presents – but in any case, my BioSocieties paper was about other stuff.