Pharmaceuticals among the sunrise industries

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understanding of disease and health care in developing countries, the need is for an analytic framework which integrates an ‘ecological’ with a ‘political economy’ approach. Department of Geography Queen’s University Kingston, Ontario, Canada

CHARLES &YINAM

No Magic Bullet: A Social History of Venereal Disease in the United States Since 1880, by A. M. BRASDT. Oxford Univer-

sity Press, New York, 1985. 245 pp. 519.85 In its preface and introduction this book promises to cover a time period from the late nineteenth century to “the current epidemics of herpes and Acquired- Immune Deficiency Syndrome (AIDS)” and to adont a oosition which emphasies the ‘social construction’ oi venereal disease, but neither pledge is fully redeemed. Perhaps it was unfortunate to make such claims because without them the book is a very readable and interesting account, seemingly carefully researched, of venereal disease and the public response it elicited earlier this century. The enticement of a social history of herpes and AIDSreproduced on the dust cover-is not well supported. As history the book is weakest in covering the period after the Second World War and the analysis of the current epidemics of herpes and AIDS amounts to barely half a dozen pages. Yet the book’s strength lies in providing an essential backdrop against which analyses of the new epidemics must take place. The earlier part of the century in America is well covered and provides a fascinating account of the constant struggle of social reformers and moralists with a disease which both marked and was spread by illicit sexual encounters. The introductory chapter however seems to promise even more for a social scientist as Brandt directs attention to the issue of the ‘social construction’ of venereal disease, in other words to ‘social definitions of venereal disease.’ There is a growing literature within medical anthropology and sociology which takes disease categories as fundamentally social in origin. In this sense venereal disease itself-and its causes, manifestations, consequences, rates, extent, etc.,-are in some way bound up with the society which recognises them. But Brandt travels only part of the social construction road and this is the book’s key failing. The ‘social construction’ of venereal disease for Brandt means two things. First, there is a thing out there called venereal disease which Wassermann and Ehrlich saw in their test-tubes. Second, there is the social and symbolic baggage which such germs attract. Brandt’s variety of social history is to emphasise the importance of the latter and to minimise, though clearly acknowledge, the former. This approach has its merits and escapes the hagiography often associated with medical histories of discovery, progress and cure. But the failure to treat the presence of the microbe, and hence the disease, in a socially critical way ultimately mars the book from the viewpoint of a social scientist. In part the book is about venereal disease as a ‘social problem’, of how campaigners and moralists made it into a ‘problem.’ But Brandt seems to believe that in addition it was somehow a ‘problem’ in its own right, particularly in terms of its epidemic proportions. At certain times he reports other’s views, but elsewhere he clearly speaks for himself. Thus, for example, he points out that despite failure to treat venereal disease in the 1920s “the staggering dimensions of the problem had nonetheless been clarified” @. 129); even with gains in knowledge in the inter-war years “syphilis and gonorrhea fluorished” (p. 131); that the “reservoir of untreated and inadequately treated infections thus grew, generating a national health problem of immense proportions” (p. 133); and so on. But how does Brandt ‘know’ that venereal disease was such a problem? Does he

believe that his historical sources represent more than an account of the symbolic domain? Surely, he seems to be saying, with all this hullabaloo and even ‘scientific’ reports of an epidemic, something ‘real’ must have been happening out there. But was there? Was there ever a venereal disease epidemic at any time this century? At an epidemiological level there are certainty grounds for scepticism; indeed Brandt himself seems aware that diagnosis tended to be a haphazard affair, that claims of prevalence often seemed inflated, that diagnostic tests produced false positives and that the incidence was constantly in dispute. Moreover, before the post-war advent of the randomised controlled clinical trial there is no epidemiological basis for evaluating the success of any prophylactic or treatment regimes. At another level, whether there really was an epidemic is unanswerable: instead, and more important from the point of view of the social sciences, is the question of the ‘case’ and the ‘rate’ of venereal disease as symbolic events. If Brandt had fully pursued the ‘social construction’ of the epidemic he reports, a different book, more based on moral panic, may have resulted. In this latter, even perceived numbers are unimportant, as can be seen by the AIDS scare which kills a fraction of those killed on the roads. The symbolic world and the microbiological world are not as separable as Brandt assumes. Unit of Sociology Medical School, Guy’s Hospital London, England

DAVID ARMSTRQSG

Among the Sunrise Industries, edited by NICHOLASWELLS.Croom & Helm, London, 1935. 240 pp. f19.95. Proceedings of an Office of Health Economics Symposium held at the Royal College of Physicians, London, 22-23 October 1984. Pharmaceuticals

The papers published in this collection are concerned with issues and problems of the ‘sunrise’ industries, focusing on the pharmaceutical industry as an exemplar. The Office of Health Economics was founded in 1962 by the Association of the British Pharmaceutical Industry. Its terms of reference are: to undertake research on the economic aspects of medical care; to investigate other health and social problems; to collect data from other countries and to publish results, data and conclusions relevant to the foregoing. Hardly surprisingly, in the main, the Proceedings reflect an industry perspective, i.e. a view from the inside. Amongst the most notable exceptions to this are the contributions by Professor Sir John Butterfield (Vice-Chancellor of the University of Cambridae). Professor Sir Richard Doll and ProfeSsor Tony Cuiyer (University of York). Professor George Teeling Smith (Director of the Office of Health Economics) epitomises the mood of many participants in a paper on ‘Politics and the Present Pattern.’ The quotation from Teeling Smith expresses a widely shared belief amongst speakers: “a series of organisations purporting to represent the broad public interest have launched a massive and concerted attack on the activities of the pharmaceutical industry throughout the world. These organisations include Oxfam, War on Want, the World Council of Churches and Social Audit, as well as the international umbrella organisation, Health Action International. These are supported by politically motivated doctors and their objectives are mirrored in the health policies of Britains two (!) socialist partiesLabour and the Social Democrats” (p. 72). The message is clear. All of us who have naively assumed that stricter control and more rigorous price competition within the industry would actually be in the pubhc interest, are simply misinformed. We are, it seems, misguided ‘do-

Book Reviews gooders’ who are insufficiently responsive to those economic principles expounded by Chamberlin (1933). Robinson (1933) and Schumpeter (1942). I shall return to this later. Central to the underlying philosophy of the Symposium is the identification of the pharmaceutical industry as a ‘sunrise’ industry. The term ‘sunrise’ industries has emerged in the context of a set of assumptions about economic growth in which the social and economic strength of the Western World in the 1980s. and beyond, will depend upon a new pattern of industrial activity. The ‘twilight’ industries (e.g. ship-building and textiles) will survive only as shadowy relics of a former golden era. The ‘noonday’ industries (e.g. engineering and aerospace) will stay ahead of competitors only by continuous infusions of new technology. It is the ‘sunrise’ industries (e.g. electronics, nuclear energy and pharmaceuticals) which provide the greatest impetus for future economic growth and national prosperity. The Symposium is structured around four main sessions (The ‘Sunrise’ Industries beyond the 1980s; The International Scene for Pharmaceuticals; Balancing Risks and Benefits; Economic Aspects) with sets of four substantive and two brief discussion papers in each. In opening the Symposium, Dr David Owen (MP) and Nicholas Wells (Office of Health Economics) assess the contribution of the pharmaceutical industry to national growth, and identify some of the difficulties the industry is currently facing. The U.K. research-based industry makes a major contribution to the nation’s economy. It discovers and develops 90% of all new drugs (with support from academic and hospital based research units), and employs approx. 70,000 people and a similar number indirectly via those industries with which it is vertically linked. Two major current problems are revealed: (1) the inadequacy of government funding for research, (2) the cost and length of time (between 10 and 12 years) major new chemical entities take to reach the medicine market from the laboratory bench. The first session on ‘The ‘Sunrise’ Industries beyond the 1980s ranges in breadth from electronics, information technology, energy (relevant since without it there could be no ‘sunrise’ industries) to pharmaceuticals. It sets the scene for more detailed discussions of the economic, political and international aspects of the pharmaceutical industry. Growth within the pharmaceutical industry as a proportion of total world gross national product-has increased from 0.58% (1960) to 0.78% (1980). This xowth is concentrated in six countries; U.S.A:, F.R.G., Japan, U.K., Switzerland and France. Nonetheless, according to Sanjaya Lall (Institute of Economics and Statistics), host governments wield the ultimate power in relation to pharmaceutical transnationals and the companies usually lose the important battles. This assumption is puzzling in the tight of recent studies, especially Gary GereflYs The Phnrmoceutical Industry and Dependency in the Third World (Princeton University Press, 1983), in which the author documents in detail the history of the Mexican steroid hormone industry from the mid 1940s to 1982. In this study, Gereffi illustrates how economic interdependence of center and periphery, in a global system, masks the basic underlying feature of asymmetrical control in the relationship which creates for the center countries and the TNCs consistent net advantages. Lall, in contrast, defines the ‘problem’ of the pharmaceutical industry in the Third World as a problem of mutual misunderstanding. In the Third World (and his discussion is limited to countries which are not ‘ideologically opposed to private enterprise and market forces’), the overriding concern is to reduce the cost of medicines to the population. This concern, or so it seems to Lall, leads to the purchase of cheap medicines from the least reliable sources on the world market. This tendency is supplemented by measures which dilute the patent system, promote local ownership of enterprises and replace brand names by generic names. AI1 of these practices, unlike the practices of the pharmaceutical TNCs (in spite of the fact that fixed-ratio antibiotic products

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have been withdrawn from the U.S. market, but continue to be imported and sold in Latin America), have implications for health safety. In consequence, the patent system must not lx further weakened and, in fact, needs to be strengthened. The problem with Lall’s argument is that the underlying conflict between national priorities (cheap and safe generic medicines for the mass of the population in the Third World) and corporate goals (the maximisation of profit), is reduced to the level of ‘misunderstanding’. This account is unconvincing. In the contemporary period, approx. 50 drug companies based in six developed countries account for nearly twothirds of total drug production and 20 companies account for about one half. The profit rates of pharmaceutical TNCs in the Third World are often higher than those operating in developed societies. To take one example: prices for Librium and Valium, produced by the Swiss based TNC Hoffman-La Roche, are lower in the U.K. than anywhere else, because the N.H.S. negotiates the prices and buys in bulk. Ironically, Mexico and Costa Rica pay more for Librium (54.42 and 57.03, respectively, for 100 lo-mg capsules) than do F.R.G. and the U.S. (S-t.38 and S5.80, respectively). The practice of differential pricing is, doubtless, one important and contentious issue, and on this La11 concedes that pharmaceutical TNCs should accept some form of price reduction in the Third World. From Lall’s standpoint, the market barriers to the entry of new competitors cheated by patents and trademarked brand names protect the consumer. One point he misses is that the position of the consumer (patient) is, in any event, exceedingly weak. It is, after all, the professional (doctor) or hospital administrator, who places the orders for the product. Another sensitive issue which La11 fails to raise in his Symposium paper is that of transfer pricing. This denotes the differential pricing of drug intermediates. Essentially. transfer prices are those prices set for intirm sales between TNC atEhates located in different countries. Here, again, there are now a number of carefully documented cases which confirm the existence of widespread abuses (Katz, 1974: Ledonar. 1975: Gereffi. 1983). On this issue. Lall’s’own early w&k is instructive (La& 1973, 1974, 1979): La11 does acknowledge that the centres of innovation and research and development in the advanced countries are directed to diseases which do not directly affect the majority of the Third World poor. In this sense, the distribution of pharmaceutical sales in the Third World does not match the pattern of disease. According to the 1980 WHO figures, total world expenditure on tropical disease research is about S30 million a year, i.e. 2% of the sum spent annually on cancer research alone. One suggestion, from Lall, for stimulating research in the area of tropical illnesses is that directed aid could be used, in this area, to make up the gap between free market prices and the low prices charged to the developing nations. It is, perhaps, odd that while insisting that developing countries must contribute to innovation, and R and D, neither La11nor any other contributor considers the role of the state-owned pharmaceutical enterprise in the Third World (see, for instance. the EI Nasr Comoanv in Eavot. and Hindustan Antibiotics Ltd in India). The-reason-becomes crystal clear in the discussion papers from sessions three and four: the market economy is (always) good; state interventionism is (always) bad. What is missing from the analysis, of course, is the reahsation that the private sector has not always responded to the social and health needs of Third World populations. One consequence of this is the generation of positive action within the stat: sector. The third session, ‘Balancing Risks and Benefits’, is very uneven. There are two excellent and stimulating con-, tributions on health care from Sir Richard Doll and Sir John Butterfield. The contributions by David Taylor (ABPI) and John Maddox (Editor of Nature) are, however, very disappointing. If they reflect majority opinion within the

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industry, the picture is a very depressing one indeed. Taylor echoes sentiments expressed by Ron Wing (ABPI) in an eariier paper in which-wing claims that the industry is being discredited bv erouns of misguided ‘liberal idealists.’ Taylor backs up td claim by drawing on the findings of ABPI opinion research which shows, to take one example, that ‘around 90% of the U.K. population understands the role of animal experimentation in medicine, in development and testing’ (this left me breathless). Now. as the mass of the population have such apparentIy high and sophisticated levels of understanding, the criticisms of the industry cannot possibly reflect the opinion of a mass public but are rather generated by an elite of ‘opinion farmers’. In this process, Esther Rantzen and the Women’s movement perform key roles! Still breathless, I moved on to Maddox’ paper. Here, I was reassuringly informed, and I had to read the sentence several times, that ‘side-effects (of drugs) are almost always unavoidable in the long run’ (p. 138), and we should all be realistic about this. The industry does its best, and the case for strict liability, in his view, is thus both inequitable and divisive. In the final set of papers, ‘Economic Aspects’, Dr Michael Burstall (Universitv of Surrey) . and Professor John Dunning (University of Reading) discuss the process and implications of decentralisation within the global pharmaceutical industry, and Duncan Reekie (University of Witwatesrand) discusses the effect on pricing and profits of changes in consumer demand patterns in response to technological innovation. The other two papers in this session (Lord Ralph Harris, Institute of Economic Affairs and Dr Clarke Wescoe, Sterling Drug Inc.) are inspired by the conviction that the market economy is good per se while state interventionism is bad. According to this view, a major negative consequence of state interventionism in Britain is that the NHS (the ‘free’ health service) has suppressed the development of voluntary hospitals and private insurance. Moreover, the NHS has prevented medical care from becoming one of the major growth services. Interestingly enough, the weakness of this position is identified and highlighted in the final discussion by Tony Culyer, who calls into question some of the more fiercely ideological assumptions heId by certain participants. His message is clear and uncompromising: any standard lower than the highest is a standard the industry cannot afford. Let us hope that the industry will heed this message. To conclude: there is no doubt that the pharmaceutical industry has made an important contribution to world health (see the discussion paper of Dr Balu Sankaran, WHO). Nonetheless, out of 16 substantive papers, only one is focused on the Third World. There is not a single contribution in which the profound and ethical problems associated with animal experimentation in the industry are seriously raised. The references to animals, as with serious critics of the industry, are both defensive and derisory. For the industry, then, “The danger of the 1990’s is that a continuation of today’s unbridled and simplistic criticism by the partially informed, whether in fields of animal rights, Third World, or even the management of Western health care programmes, will produce a diminution of the resource available to discover, develop and distribute the benefits which, science can realistically achieve in the next decade” (Ron Wing, President of the Association of the British Pharmaceutical Industry). Department of Sociology Uninicersityof Lancaster Bailrigg, Lancaster, England

GTE

CURRIE

Krankheit und Kultur: Eine Einfuhrung in die Ethnomedizin

(Sickness and Culture: An Introduction to Medical Anthropology),by BEATRIX F'FLEIDERERand WOLFGANG BICHMAN.

Foreword by THOMASMARETZKI.Verlag. Berlin, 19Sj. 263 pp. No price given. This is an important book for medical anthropology in Germany and German-speaking countries. Written from the perspective of an experienced ethnographer (Pfieiderer) and an anthropologically engaged physician (Bichman), Krankheif und Kulfur is an authoritative introduction to the field which draws on the authors’ many years of field experience in India and Africa, respectively. It makes accessible to German speakers for the first time the conceptual formulations and substantive contributions of American and British medical anthropology. Major chapters deal with medical systems in historical perspective, cultural foundations of illness classifications, healer/patient interaction, medical pluralism and, finally, primary health care in developing countries. These topics are discussed with a special focus on South Asia and Africa, the authors’ geographic areas of expertise. The book is intended for professionals and others involved in medicine and international development as well as for use in courses on medical anthropology and on medicine in developing countries. Krankheit und Kultur, however, has much to offer beyond a well-written introduction to the subject matter of medical anthropology. It traces the development of European, and particularly German, medical anthropology (‘Ethnomedizin’). I found particularly interesting the discussion of the origins of the modern field of Ethnomedizin which is rooted in a branch of medicine called ‘medizinische Anthropologie,’ first established in the 17th century. It is enriched by a long tradition of interest in European folk medical systems and has received new impetus from the necessity to provide appropriate medical care to foreign ‘guest workers’ who have swelled the ranks of the German work force in the last decades. An additional factor was German development assistance provided to Third World countries, including the education of foreign physicians and health care workers. Contemporary German Ethnomedizin, then, took shape based on this tradition but, as the authors point out, was also substantially shaped by American and, to some extent, British medical anthropology. Given the long-standing preoccupation of German ethnology with culture trait analysis, it is gratifying to see that the authors employ throughout a broad cultural, historical and sociopolitical framework which locates the proper domain for medical anthropology (and its application) in the universe of human relations. Illness episodes and individual acts of healing are consistently presented as arising from the social environment in which they occur. The political role of cosmopolitan medicine is highlighted by the translation of ‘cosmopolitan’ medicine as ‘cosmopolitical’ (kosmopolitische) medicine, thereby calling into question the neutrality of the term and throwing into relief the role of western medicine in establishing and maintaining power relationships. The political grounding and political efficacy of cosmopolitan medicine with its ties to the interests of former colonial powers and to those of Third World elites forms part of a sophisticated analysis of health care systems and health seeking behavior. While clearly written, this is not just an introductory text. There are trenchant original analyses of several issues. For example, the authors provide one of the most comprehensive and insightful discussions of the history of medical systems in Africa and India, illuminating the complex relationships between the interests of missionary churches, colonial powers and the populations concerned. There is an excellent analysis of the role of the World Health Organization in Third World development, particularly through its sponsorship of the idea of primary health care (PHC) and its attendant goal of Health for All by the year 2000. The concept of PHC, as originally envisioned, would demand social structural transformation. It deemphasizes the sick individual, focusing instead on the