We are at a moment of crisis. The narrative of the left blames neo-liberalism, while that of the right the deep state. They are both wrong. Understanding the origins of the current health crisis - one of many - is the key to understanding everything else. Sometime in the 1960s, a managerial logic took over the health sector. Doctors’ human judgement was replaced by algorithmic thinking and reliance on metrics that could be manipulated with drugs replaced the lived experience of patients. Then the same happened to economics. Unthinking techniques and reliance on metrics eventually seeped into politics. Curing contemporary medicine of its technocracy could be the model for resolving all our other crises, argues David Healy.
Rising global temperatures and increasing degradation of the environment with plastics and toxins grab our attention and leave little room for any awareness of the crises in health and social ‘care’ that may engulf us before any rising tide does. Covid disproportionately killed not just the elderly but those in ‘care’ homes. Even before Covid, however, life expectancies for all of us were falling (1). Our abilities to care for either ourselves or the environment are at crisis point, and crises like these call for leaders, but no leader seems able to treat the fractures in our politics. The Left blames neoliberalism for everything going wrong. The Right invokes a Deep State. Does anyone know what either of these is – other than the enemy? Are they the same thing?
Greed, rent-seeking and sharp practice in money matters predated the capitalism that emerged around 1800, one based on technologies that offered new opportunities to make money from investments in production rather than speculation. The supply of goods, wealth, and a belief in techne grew, and grew even quicker where socialists had a seat at the table where decisions about production were made.
Greed and sharp practice in health matters predated a medicine that emerged around 1800 based on a medical model that embraced technologies, offering new opportunities to save lives and reduce disability. Life expectancies began to rise, disabilities to fall, and a belief in techne grew. Health became a key card for socialists seeking to make industry work for all of us.
Every technology embodies a technique, an algorithm, a rule. After defeat by Napoleon, Prussia (Germany) initiated government by technique (rules), a bureaucracy. The intention was to limit the discretion of the powerful by standardising procedures.
All techniques are efficient. Standardization makes them scalable. Efficiency and scalability inevitably create an arms race - the most efficient weapons in the greatest numbers win wars - and a drive toward globalisation. But the intelligible component of a technique replaces our judgement and discretion. Techniques do rather than think; they are amoral. We are responsible for whether they enhance or diminish us. This is more obvious in the case of a technology than a technique.
Techniques do rather than think; they are amoral. We are responsible for whether they enhance or diminish us.
How management consulting ruined medicine
Techniques laid the basis for a management science, operationalism, that in the 1950s and 1960s underpinned corporate development in government, churches, and companies, and conditioned us to the idea of technocracy - a short step from neoliberalism and Deep States.
Analyses of the crisis we now have in social care point to a consolidation of residential homes, with outsourcing or subcontracting of work to specialist cleaning, catering, and care-staff companies, in the name of efficiencies that happen to also yield a maximum return on investment. This is cast as neo-liberalism in action. But it is also standard management practice.
In the 1960s, management consultants advised pharmaceutical companies to outsource their clinical trial and medical writing divisions, and later drug discovery and public relations. It gave us Contract Research Organizations (CROs), a $40 billion industry, that runs all pharma trials, and sequesters the data from those trials so no-one, not even regulators, sees it. It gave us medical writing companies, who now ghostwrite the literature on on-patent drugs appearing in the most prestigious medical journals. For thirty years, the greatest concentration of Fake literature on earth has centred on the medicines our doctors give us.
Adopting operationalism, both private American and public British hospital systems outsourced swathes of employment, like cleaning and catering, decades before Uber began to do the same.
The Left blames Reagan and Thatcher, but they favoured a risk-taking entrepreneurialism not the corporate risk management and corporate bureaucracy that management technique has given us. Looking at health in the 1990s, Milton Friedman saw increasing socialism, a Deep State, while the Left saw neo-liberalism.
Doctors began treating figures rather than patients in the 1960s.
Metrics, neo-liberalism and neo-medicalism
Friedman and the Chicago School threw a further element into the mix when they advocated controlling the money supply to remedy the problems of the Chilean economy in the 1970s. Adam Smith’s free market was not a slave to figures. Monetarism was following in medical footsteps where metrics took hold a decade earlier.
Controlling the money supply was as irrelevant to economic health as controlling blood pressure, blood sugar, bone density or other figures are to saving the lives of people having heart attacks, strokes or in mid psychosis.
Doctors began treating figures rather than patients in the 1960s. This was heavily marketed by pharma in the 1980s as risk prevention. Where once we brought problems like angina to doctors, clinics summoned us to have our cholesterol and other figures checked, giving us problems for which drugs were the answer. Polypharmacy came into being and with it a 20-fold increase in the sales of pharmaceuticals (1).
Controlling the money supply was easy, but bad for the Chilean economy, just as controlling medical figures is easy, but doesn’t treat a heart attack. Controlling the figures can result in quality outcomes. But giving ‘poisons’ to people who are well to get the figures looking good, gave us a pharmaceuticalization where drugs chase drugs while disability increases, a process paralleled at the same time in the financialization of the economy in which money began chasing money while poverty rose.
This financialization combined with outsourcing differed as much from a prior productive capitalism as pharmaceuticalization combined with outsourcing differed from what had been medicine. In one case we have the emergence of neo-liberalism and Deep States and in the other the emergence of a neo-medicalism that might shed light on what neo-liberalism is and ways to combat it.
David Healy uncovers the politics of unpopular research.
As it is for doctors and the human body, it is easier for economists and politicians to treat ‘objective’ figures than to engage with the complexity of a body politic. But these are reflex actions triggered by figures, an unthinking automatic doing, that distorts the running of a country, distorts what had once been healthcare, and, applied to a maximizing shareholder value metric, distorts the nature of companies.
Before he died in the 1920 influenza pandemic, the German social scientist Max Weber foresaw us locking ourselves into an iron cage of process, an unthinking automatic doing. Avoiding this fate would not be a job for bureaucrats. Ultimately political leaders, acting like doctors, would need to get people to take their medicine, even though the cure might be painful.
A medicine is a perfect symbol of our current dilemmas. It is a chemical technology, a poison that once came wrapped in lived medical experience aimed at helping us bring good out of its use. Now it is wrapped in informational techniques. Like all technologies, medical chemicals have 100 possible effects, of which one or more may be therapeutically useful and one, not necessarily the same, commercially useful.
In 1962, amendments to the US Food and Drugs Act made randomized controlled trials (RCTs) the technique through which pharmaceutical companies got a drug on the market. This made RCTs the standard through which companies would make gold. Companies now spin RCTs as offering gold standard knowledge of what drugs do, even though, as an algorithmic technique that can only evaluate one of a drug’s effects at a time, by definition they are not a good way to evaluate a medicine which has 100 effects. The 99 other effects essentially vanish. A turn to RCTs transformed drugs, which had been poisons, into sacraments – something that can only benefit (1).
As with all techniques, RCTs prioritize efficacy over safety. They produce a medical version of handling the school shooting problem by having a good guy with a gun outside every school. We sense that having drugs and guns proliferate and letting them leak into places they should not be is not safe. Although efficacy based on a ghostwritten literature cannot be solid, it still trumps common sense and doctors now dish out drugs with a liberality beyond the wildest dreams of the National Rifles’ Association.
As it is for doctors and the human body, it is easier for economists and politicians to treat ‘objective’ figures than to engage with the complexity of a body politic.
RCTs create a GDP-like metric. They foster activity with drugs, whether to treat blood pressure or the consequences of blood pressure medication. Giving a poison to people who don’t need it is problematic, as is giving more than one poison at the same time. It needs discretion rather than reflex prescribing, but the technique of RCTs embodied in the process of Evidence Based Medicine increasingly inhibits both our judgments and those of our doctors.
In a truly terrible irony, when antidepressants cause suicidality what can a doctor treat it with except an increased dose of an antidepressant? Nothing else has been through an RCT for treating suicidality. Our doctors now have no option but to keep digging the holes they increasingly put us in.
Just like every oil spill adds to GDP, every drug-induced adverse effect increases health spend. Just like GDP doesn’t measure the air we breathe, the number of trees we see, or access to unpolluted seas and rivers, so some of these other drug effects, such as inhibiting our ability to make love, may be more important to us than correcting an irrelevant minor deviation in blood pressure or rating scale score. But doctors are now paid to get our figures looking good.
Gross Health Costs are approaching 20% of GDP in the US. Correcting our blood pressures, blood sugars, bone densities or rating scale scores are now more likely to land us in hospital than leaving these untreated, but drug adverts spin these preventive treatments as reducing overall health costs (1).
What other outcome could there have been if there is no access to the trial data showing that the problems we figure we are having, which our doctor denies could be caused by treatment, were in fact present in the inaccessible trial data but not in the ghostwritten trial reports? If these reports then form the basis for Evidence Based Guidelines, adherence to which are written into our doctors’ job contracts, or implicitly required by management, there can be no other outcome.
You would imagine politicians could insist on access to trial data but seemingly not. They go with a flow that implies that there are checks within the process to correct whatever needs correcting. But between outsourcing and everyone having their own specified brief to get their set of figures in the best shape, there is no-one in a position to say that this supremely rational system is increasingly insane. Technocrats always opt to add a touch more process rather than diagnose insanity.
Between outsourcing and everyone having their own specified brief to get their set of figures in the best shape, there is no-one in a position to say that this supremely rational system is increasingly insane.
Treating Our Psychosis?
Just like treating a heart attack, we need to stay awake and able to make judgment calls, rather than operating under an algorithm-induced hypnosis. This is not about abandoning techniques but about realizing that if we want them to enhance rather than diminish us, we need to embed them within judgement calls we make. Several studies now point to a longer life, better quality of life and fewer hospitalizations if, based on our judgement calls, we reduce our reliance on techniques and take fewer drugs.
Technical efficacy has limits. Giving more sedative drugs to people in residential care is no more the answer to problems of ‘care’ than turning to geo-engineering is to climate change.
All technologies are in a sense like drugs, a poison from which we can bring good. This multidimensional reality does not fit into the unidimensional flowcharts of managers, insurers, or bureaucrats. The market figures that the Right turns to cannot comprehend this, any more than the regulations and other process-based systems in which the Left believes.
Around 1990, facing a life-or-death crisis and opting to take a stand on the value of enabling people to live the lives they wanted to live, those who then had AIDS found a path between Left and Right, discovering Triple Therapy without any RCT input and not beholden to any metric. It took a crisis, but it can be done.
Caring means having the courage to say that no matter how good this process or these market data look on paper, the collective judgements of those on the receiving end of the practices, and their willingness to take risks, such as not taking all the drugs guidelines recommend, counts for more than the apparently rational views of those who assembled the flowcharts.
Similarly, caring for the environment may be helped by technologies but only if we embed them in judgement calls that forego many possible options - not as a matter of restricting our liberty but rather recognising we get more of what we value if we judiciously deploy techniques rather than submit to their logic.
Healy D (2021). The Shipwreck of the Singular. Healthcare’s Castaways. Samizdat Health, Toronto.