Drugs as Multilayered Stabilizing Agents?
Text by Saskia Sturm (Freie Universität Berlin)
Art by Pablo Dohms
The following essay deals with an urgent aspect of the relation between mental illness and health and social inequality: the use of medication for therapeutical purposes and its interplay with the pharmaceutical industry. I shed light on the intertwining political and economic interests of generating profits as well as exercising social control with pharmaceuticals. When financial gains determine access to treatment and medication, can there be such a thing as social equality? Or are we instead confronted with a new form of survival of the fittest in a neoliberal fashion? João Biehl’s fieldwork in Brazil, which he began in 1995 and conducted over several years in an institution called Vita, will serve as an example to illustrate the connection between psychopharmaceuticals, economic interests and societal ramifications. One of his key informants, Catarina Morae, a woman with migratory background, loses it all and experiences what might aptly be called “social death” in this so-called social institution. Abandoned by friends and family, her life revolves around the relationship with a different kind of agent, one which is supposedly the solution to her suffering: psychopharmaceuticals. But are they, in fact, poison or remedy?
Introduction
In my previous essay ‘Racism in Psychiatry. A Postcolonial Aftermath?’ (Sturm 2022), I described the relation between (post-)colonial structures and the so-called ‘psy-disciplines’[1]. I targeted social inequalities and injustice by demonstrating how the origination of therapy, clinical procedures, science, research, and discourse in academia are structurally connected. I argue that the outcome of therapy and its underlying theoretical foundation does not always help and heal those affected, due to the systems of racism inherent in all areas named above. They build on an unprecedented production of inequality invented by a small part of the world’s population for their benefit. This form of colonialism is consolidated by a biological explanation of hierarchy and world order. By illuminating the specific context of the development of psychology and psychiatry, that is, as a consequence of post-Enlightenment thinking and philosophy in the European and Anglo-American world at the end of the 19th century, I aimed at deconstructing the approach of so-called universal theories and practices in psy-disciplines that imply physical measurability as a qualitative criterion for ‘proper’ science. I have discussed how psychiatry and anthropology, despite having quite similar origins, soon diverged as disciplines, with psychiatry evolving into a more biological and neuroscientific direction. This tendency also represents the current hierarchy of disciplines in academia. The prevailing approach to controlling and treating mental illness in public care institutions, such as psychiatric hospitals, as well as in the domestic sphere, is the use of medication—in other words, targeting physical processes. There is, however, a lack of attention on social inequality to explain problems and illnesses in different communities. I argue that psy-disciplines need to more thoroughly consider a person’s (social) environment—in therapeutic contexts as well as theoretically.
In this essay, I will examine different facets of the use of psychopharmaceuticals, their therapeutical purposes, and the interplay with the pharmaceutical industry. It is an attempt at shedding light on the connection of mental illness and health and the production of (forms of) social inequality. As Adriana Petryna and Arthur Kleinman put it in their article The Pharmaceutical Nexus: “[w]orldwide, images of well-being and health are increasingly associated with access to pharmaceuticals” (2006, 1). Since the industry is worth billions of dollars, there is an evident economic incentive to substantiate this hegemonic view. In neoliberally organized political regimes and markets, political interest is not limited to generating profits with pharmaceuticals, but extends to a level of social control. One might associate pharmaceuticals with the idea of generating help and support to recover from illness. But the figures of the pharmaceutical industry tell a different story. While diseases like HIV/AIDS and multi-resistant tuberculosis are still detrimental—and often deadly—to large parts of the population, especially in poor and politically unstable countries, global sales of anti-depressants and anti-psychotics seem to soar disproportionately (ibid., 2006, 2). I wonder, is the main motive of the pharmaceutical industry to take care of the survival and well-being of humankind, or is it mostly about sales?
Health Care for Sale?
According to Articles 3 and 25 of the Universal Declaration of Human Rights (United Nations 1948) there is an apparent global consensus, that human life needs to be protected and that there is a right to health care. When pharmaceutical profits determine access to treatment and medication, however, such declared commitments to social equality must be called into question. Instead, there seems to be a new form of survival of the fittest, economically speaking: the one who is born in the right place and is financially affluent receives access to the appropriate medication, whereas other parts of the world are, freely spoken, doomed.
The foremost objective of developing pharmaceuticals has been providing effective treatment for the largest possible section of the population. To ensure the efficacy and safety of medication, regulatory entities have been installed in the 1960s. Prior to that, researchers often used to test the pharmaceuticals on themselves and more and more of such trials have been invented, which may admittedly not have been the safest method of testing. Randomized controlled trials (RCT) and other clinical tests subsequently introduced new parameters for the efficacy of pharmaceuticals. Alternative ways of treatment, such as nature therapy, did not perform well in that kind of testing and therefore have been deemed less efficacious. This new way of constructing effectiveness excludes factors that are not easily measurable, such as the relationship to the therapist, the environment, or expectations and ritual practices (Hardon and Sanabria 2017, 119 f).
Scientific measurement plays a vital role in many of today’s disciplines and is meant to generate a feeling of security for consumers who wish for fast and reliable healing. Much trust is put in the diagnosis of medical authorities and the prescribed medication without considering the ramifications of the pharmaceutical industry’s interests in ever increasing profits.
The connection between the pharmaceutical industry, therapy, (institutional) science, and politics I have introduced this far, has for a long time been discussed in terms of “structural violence” (Goldstein 2007). Medical anthropologists criticized a dearth of cultural factors in the structural violence approach, while for poststructuralist anthropologists it was the idea of universal or moral aims that needed to be questioned (ibid., 44). According to this criticism, there needs to be a stronger focus on structures of power in institutional systems as well as an awareness of other connections beyond the structural and institutional level, to grasp more facets (ibid., 45). Or, as Illouz (2008, 20) puts it: “[…] ideas and meanings can become dominant not only when they undergo institutionalization but also when they help us ‘do things’, that is, cope with and resolve practical questions.” That does, of course, not mean that those powerful and often flawed structures should not be scrutinized, but there is a lot more to consider. It is a complex system, which might never be fully revealed by a universal theory but described and understood more comprehensively by taking closer look at all the nuances. Anthropology in particular offers opportunities to undertake close examinations on a micro-level and to relate it to theories and information from a macro-level as well.
The Case of Catarina Moraes
I would like to illustrate these theoretical considerations with João Biehl’s (2004) research in an asylum called Vita in southern Brazil. From 1995 on he conducted fieldwork over the course of several research stays in that institution, where he worked on the interface of psychopharmaceuticals, the domestic economy, and social abandonment. One of his main interlocutors, Catarina Moraes, has been diagnosed mentally ill and was eventually left behind by her family in the so-called social institution Vita. This case vividly demonstrates how the prescription of psychopharmaceuticals is intertwined with economic and social factors. It is the individual fate of a migrant woman whose life was shaped by growing up in poverty and with a sick mother. Suffering from a genetic disease, she is initially misdiagnosed and treated with psychopharmaceuticals. Her family abandoned her after several years in psychiatric treatment and left her in Vita, a place for “social death” as Biehl (2004, 482) calls it. This showcases the belief in the capability of pharmaceuticals and the biases resulting from it. Catarina’s family trusted a poorly founded diagnosis and the accompanying medically advised treatment with potent drugs. This acceptance simultaneously worked as an excuse for abandoning their supposedly mentally ill wife, sister, and mother, who seems to be better off with medication and with people in similar situations within this institution—rather than taking care of her at home. The standard of care at Vita, however, is poor and medication is used to tranquilize the inhabitants. Medical attention does not extend beyond the treatment of the most obvious afflictions, as Captain Oswaldo, responsible for Vita’s administration admits: “We cannot bring them back to society. As horrible as it is, here one sees a truth” (Biehl 2004, 483).
It is worth noting that her illness might in fact have had various other causes. The feeling of abandonment likely contributed to her deteriorating health. Other factors include her self-diagnosed rheumatism, which has not received any medical attention, side-effects of the medication or a general lack of comprehensive medical treatment. Vita as an institution is neither financially nor socially equipped to provide all those levels of care. This circumstance is bypassed in practice with the prescription of psychopharmaceuticals and, consequently, the sedation of inhabitants. In a notebook called “my dictionary”, Catarina describes her relationship with the prescribed drugs. In that diary, she gives herself the nickname Catkini—a reference to the drug Akineton (Biehl 2004, 486 ff).
The Pharmaceutical Drug as an Agent
Within this web of interconnected issues the pharmaceutical drug may be considered as a significant agent, one that deserves further attention in order to broaden the understanding of the situation of people like Catarina. Once a drug is taken it is not gone, but rejoins the world in the form of separate components that continue to affect the environment. Such considerations allow to conceive of them as “fluid drugs” (Hardon and Sanabria 2017, 125). This theory recognizes a drug as the sum of its parts. The drug itself as an agent is also part of the whole. In a similar way, the different factors in Catarina’s life that contributed to her illness cannot simply be reduced to a psychic disorder. Psychopharmaceuticals can provide an easy solution by for people, like Catarina, that do not fit in—by tranquilizing them. The idea of how to live properly and how deviations are evaluated is determined by a neoliberal system that is based on a universalizing rationale: the idea that every disease can be treated with utmost precision by using pharmaceuticals. This, of course, neglects other factors aside from physical processes. Pharmaceutical treatments can stabilize this neoliberal system by allowing other members of society, in Catarina’s case her family, to go on with their lives and maintain their labor force and purchasing power. Meanwhile, the inhabitants of Vita serve as a deterrent for people who get treated there temporarily. They must come to terms with the realization that this asylum will be their final destination if they cannot change their lives (Biehl 2004, 485). This observation shows how the micro-level (Catarina’s case) is interwoven with the macro-level (pharmaceutical treatments as a stabilizer of social order within a neoliberal system).
The most interesting twist in Catarina’s story is her examination in a clinic by a renowned genetic team, initiated by Biehl. It revealed that her problems with walking, which had been the initial reason for her job loss and abandonment by the family—the beginning of a downward spiral—indeed has a somatic cause: a genetic disorder called Machado-Joseph Disease (Biehl 2004, 490). Since such factors had not been considered before and her condition has consequently never been diagnosed, psychopharmaceutical medication served as a rapid solution for Catarina’s assumed illness. The psychiatric strategy of treating her with pharmaceuticals and simply doubling the dose when she discomforts her family implies two things. On the one hand, it makes the family “proxy psychiatrists” who are allowed to decide the dosage of Catarina’s medication (Biehl 2004, 489). And on the other hand, it shows how the prescription of potent psychopharmaceuticals may occur without an adequate diagnosis. In this scenario, the semblance of scientific conduct works as an excuse for her family members to justify Catarina’s abandonment and other ethically dubious actions. During the further progression of her disease, it is not clear anymore if the medication is friend or foe—it remains opaque which developments may have actually been caused by the pharmaceuticals. As Petryna, Lakoff, and Kleinman have put it: “Psychopharmaceuticals are central to the story of how personal lives are recast in this particular moment of socioeconomic change and of how people create life chances vis-à-vis what is bureaucratically and medically available to them” (in Biehl and Locke 2010, 325). Nobody cares for the poor that are no longer able to support the system, like Catarina. Under the pretense of adequate help, people can be abandoned in allegedly caring institutions which are their personal but also societal final destination. Social death precedes physical death, and the way is paved with pills. As I already articulated in my last essay, I am not an opponent of psy-disciplines or the use of psychopharmaceuticals per se. But there is a lot more to it, than the well-being and the healing function which supposedly work immaculately, i.e., based on biological calculations and monitored research. I wanted to elucidate the many intricate connections which come together in an individual fate. There is no way of universal theorizing, diagnosing, or healing because so many distinct aspects have to be taken into account. Anthropology can help reveal such connections. With ethnographic case studies, such as Catarina Morae’s, the discipline is able to show how the struggle for (a self-determined) life and belonging manifests for specific individuals, situations, and local conditions and circumstances.
Conclusion
The misdiagnosis of people as mentally ill is facilitated by the entanglements of psychiatric and neoliberal rationalities. The anthropological perspective can “articulate more immediately relevant and experience-near conceptual work” (Biehl and Locke 2010, 335). This nuanced understanding of interconnectedness can make a difference and counter neoliberally conditioned modes of thinking, discourse, and action and pave the way to more social equality. In closing, I want to share and excerpt from Catarina’s ‘dictionary’ which expresses so much structural understanding through poetry:
The dance of science.
Pain broadcasts sick science, the sick study.
Brain, illness.
Buscopan, Haldol, Neozine.
Invoked spirit
(In Biehl 2004, 487)
Notes
[1] Suman Fernando uses the term ‘psy-disciplines’ as an umbrella term for Psychology and Psychiatry in their different forms (2017, 3).
References
Biehl, João. 2004. “Life of the mind. The interface of psychopharmaceuticals, domestic
economies, and social abandonment.” American Ethnologist 31 (4): 475–496.
Biehl, João, and Peter Locke. 2010. “Deleuze and the Anthropology of Becoming.”
Current Anthropology 51 (3): 317–351.
Fernando, Suman. 2017. Institutional Racism in Psychiatry and Clinical Psychology. Race Matters in Mental Health. London: Palgrave Macmillan.
Goldstein, Donna. 2007. “Life or Profit?: Structural Violence, Moral Psychology and Pharmaceutical Politics.” Anthropology in Action 14 (3): 44–58.
Hardon, Anita, and Emilia Sanabria. 2017. “Fluid Drugs: Revisiting the Anthropology of Pharmaceuticals.” Annual Review of Anthropology 46: 117–132.
Illouz, Eva. 2008. Saving the modern soul. Therapy, emotions, and the culture of self-help. Berkeley: University of California Press.
Petryna, Adriana, and Arthur Kleinman. 2020. “The Pharmaceutical Nexus.” In Global Pharmaceuticals, edited by Adriana Petryna, Arthur Kleinman and Andrew Lakoff, 1 –32. New York: Duke University Press.
Sturm, Saskia. 2022. “Racism in Psychiatry? A Postcolonial Aftermath.” [anthro]metronom (blog). https://www.anthrometronom.com/post/racism-in-psychiatry-a-postcolonial-aftermath
United Nations. 1948. Universal Declaration of Human Rights. https://www.un.org/en/about-us/universal-declaration-of-human-rights