From apps to doctor's offices, we are being given more and more data and detail about our health. We are then given the drugs we need to balance each person's collection of conditions. This however argues David Healy is just the result of the neoliberal target setting pharmacology establishment pushing drugs to treat life. He argues for a rejection of this treatment in his continuation of Technology and the demise of medicine.
Targets created economic neo-liberalism. Targets emerged simultaneously in medicine and illustrate the ramifications of neoliberalism.
Treating diseases was the traditional goal of medicine. Up to 1980, doctors measured blood pressure, glucose and cholesterol levels, bone densities, and scores on rating scales as an aid to treating heart attacks, diabetes, or psychoses.
In 1981, blood pressure, glucose and related targets treating which would prevent heart attacks or psychoses. Services reorganized themselves to screen for and treat numbers. Before 1980, we brought our problems to doctors, after that medical clinics began to summon us for screening and gave us problems we didn’t know we had. Rather than the market in health shrinking as prevention suggests, it expanded dramatically.
Pharmaceutical companies focused on treatments to manage these targets. Around 90% of company profits are made from medicines to treat targets rather from medicines to save people having heart attacks, strokes, or psychoses. Where once we might have taken a time-limited treatment for one disease, we were soon being treated in perpetuity with multiple drugs.
In contrast, the few new drugs that save lives, like Triple Therapy for AIDs or Solvadi for Hepatitis, bring immense pressure to lower the treatment price, leading to less profits than marketing medicines to the healthy, leading Goldman-Sachs recently to declare that saving lives is not a good business model.
The financial crisis of 2007 hinged on a financialization driven by neoliberal targets that replaced an exercise of discretion based on political judgements beyond numbers.
Mental health has seen no breakthrough drugs for the management of psychoses, or mood disorders, for over sixty years, but vastly more money is made treating a rapidly increasing proportion of the population who would never have been viewed as mentally ill before 1980. Astute marketing departments turn our rating scale score into wants, even needs, creating a booming wellness industry. We now seek optimization in a competitive market rather than treatment for an illness.
Health targets can enable us to govern or sabotage ourselves. In the 1860s, scales on which to weigh ourselves appeared. A decade later, a new condition, anorexia nervosa, was described. Anorexia became more frequent in the 1920s when the life insurance industry linked weight to health, and public weighing scales began to carry ideal weight norms pinned to them, with beauty linked to these norms. Eating disorders mushroomed in the 1960s as weighing scales migrated into our bathrooms but remained close to non-existent in countries without scales.
Scales, like stopwatches or any measuring instrument, offer a tool through which we can control an aspect of our identities. But their use becomes maladaptive, even life-threatening, if we measure one aspect of our lives intensely and neglect all else. If we cannot measure everything and synthesize all measurements, we risk being infected by the data we collect. Just as social conditions and constitutional differences interact with microbes to produce infections, social conditions and temperaments interact with measurements to infect our identities.
The emergence of Apps generating lots more numbers for which companies will have remedies – because we are worth it – can only aggravate this problem. Measurements and techniques are morally neutral. Whether they enhance or diminish us, enable us to govern or destroy ourselves, hinges on our judgements and choices.
Measurements, like hypnosis, subvert our ability to make judgements and to choose. Numbers create an almost moral onus to get our numbers right. Choosing to ignore the figures can break the spell.
HealthCare to Health Services
Targets offered an opportunity to manage doctors who were managing our numbers, which underpinned a transition from healthcare, supported by administrators, to health services run by managers.
Algorithms began to replace clinical judgement – your blood pressure or cholesterol is high, take this. Resources lined up behind the algorithm in that health service companies could be reimbursed not just for detecting higher cholesterol or blood pressure but for ensuring that a proportion of those detected got treated. Fail to get treated and we might now be struck off a doctor’s list or refused insurance.
Prior to 1950, entrepreneurs ran businesses but recognized that while they had a good business idea this did not equip them to be a skilled machinist or bookkeeper. Entrepreneurs resembled the religious orders who ran hospitals without thinking they knew better than doctors or nurses how to diagnose and treat.
A shift to management began in the 1950s as led to a drop in the numbers of those working in manufacturing, who moved instead to the emerging service industries. Service industries, which run on operations that can be charted in flowcharts and where quality means ensuring everything is done exactly the same way every time, are the natural habitat of managers.
Nobody expected healthcare to become a service industry. Starting in the 1980s, this happened, underpinned by the change from treating diseases to screening for targets, as drugs more reliably moved targets in the right direction than they did when used to treat heart attacks or psychoses.
In the 1840s, a thinning of bone density linked to rare fractures was labelled osteoporosis. From 1980, companies marketing bisphosphonate drugs distributed free bone scanners to medical clinics. A new technically defined osteoporosis became vastly more prevalent than the old illness. The new diagnosis happens decades earlier than before and leads to maladaptive inactivity. The treatments now given to people with minimal bone thinning make serious fractures more likely, an unsurprising consequence of abnormally thickening bones.
Drugs to manage blood sugar lead to more hospitalizations than Type II diabetes. We are encouraged to avoid high glucose levels at all costs but not told that lowering glucose levels can lead to dementia. Statins can lower our cholesterol levels but not death rates. They do, however, transfer our likely cause of death from a cardiovascular one to a cancer but we are not asked whether we would prefer a quick and painless death to a slow and painful one.
Notionally consensus meetings of medical experts routinely alter the targets so that ever more of us are defined as at risk. Rather than being told we have some risks, we are told we have several chronic medical disorders. The rates of these chronic medical disorders are increasing in parallel with the number of medicines we consume. The early antibiotics, in contrast, led to the closure of infection wards.
The turn to health targets was fortuitous for Margaret Thatcher and her health advisor, Alan Enthoven. Making health numbers available to all, Enthoven argued, would incentivize staff. The medical elite who had run healthcare from the top down would fall away and innovation would flourish.
Medical elites were replaced - by a managerial elite. Thatcher recruited Roy Griffiths, a supermarket Chairman, to advise on managing a health market. Britain’s National Health Service had previously been supported by an administration, whose costs took up 3% of the budget. The costs of managers soon exceeded 10% of the budget.
Managers, spun as bringing an enterprise ethos to public services, would spot opportunities. But unlike entrepreneurs, who depend on gut instincts rather than numbers, managers manage what they can measure. The new service numbers were always more likely to flag up risks to the organization than ways to advance the common good.
Before 1980, a physician’s job was to mobilize the resources of the organization s/he worked for in our interest when we had a life threatening problems. After 1990, the physician’s job was more likely to be one of managing the risks we might pose to the organization. We felt the change when we sought Care.
Medicines are not Pizzas
Up to 1990, it was hallowed wisdom that healthcare involved efforts to bring good out of the use of a poison (physicians) or a mutilation (surgeons). This does not compute for health managers, insurers, or politicians. Managing health services has problems not found in other service industries. The medicines that are a central part of what these services now offer illustrate this.
A medicine uniquely combines a technology, the chemical, and a technique, the information central to its use. Like all technologies, medicines come with instructions for their use – take three times a day. But the information also speaks about the lives we want to live. This was formerly imparted in a relationship with a doctor, born from her experience. Now it lies in a drug label, born from company efforts to get us to live the life they want us to live.
Up to 1980, physicians ran the studies that brought drugs to market. After 1980, companies outsourced their studies to Contract Research Organizations (CROs). While physicians still appear on the authorship lines of articles, since 1990 these articles are authored by medical writers. Neither physicians nor regulators have access to study data.
Lack of access to the data means these studies no longer meet scientific norms. A significant proportion of the medical literature claims benefits and safety the data does not support. In some areas of medicine, the mismatch between the data when accessed and the published claims is comprehensive. Our information for prescription drugs is now no more reliable than our information on financial products was in 2007.
The marketing of drugs has achieved the ultimate goal of propaganda – invisibility. We ignore the glossy adverts in medical journals, and focus on the apparent science, which is the propaganda that sells drugs.
Tony Hill ran the first Randomized Controlled Trial in Britain in 1947. In 1962, following the thalidomide crisis, Louis Lasagna incorporated RCTs into the 1962 Food and Drugs Act..Both men agreed that RCTs give us the average effects a drug can have but tell a doctor very little about how to treat the person in front of them. In Medical Trials, doctors make judgement calls picking out patients who suit one medicine but not another and whether in some cases the treatment is injurious but these now account for less than 10% of RCTs undertaken.
Company in contrast run assays designed to meet a regulatory standard rather than trials aimed at informing clinical practice. They aim at a commercial benefit on a surrogate outcome such as lipid levels or rating scale scores. Meet this target, on average, and just as with the use of words like chocolate and butter, regulators will let a company use a word like antihypertensive or laxative without any qualification suggesting some may be harmed.
In an RCT statistical methods should only apply to one effect on which the figures are well collected. But companies apply them to poorly collected data on adverse effects to claim the science shows their drugs have no adverse effects even though more people have died on their treatment than on placebo. Statisticians condemn this unreservedly but companies persist as this approach offers them, A Stop-Go mechanisms that appeals to regulators, and also to managers, and insurers. It stands in stark contrast to clinical practice which should embrace uncertainty.
We ignore the glossy adverts in medical journals, and focus on the apparent science, which is the propaganda that sells drugs.
Built into guidelines, company assays command doctors to prescribe and us to take. Managers then assess the competence of doctors by checking how well they keep to guidelines. Doctors have become technicians or bureaucrats rather than professionals. Insisting this drug does not suit that patient is increasingly like a politician attempting to stand up to Hedge Fund.
The effect of company studies has been to convert the 3-dimensional reality of giving a drug, which has multiple effects and involves trade-offs, into a 2-dimensional operation, from which there can only be a benefit. This 2-D operation fits as neatly into a flowchart as delivering a pizza to a customer. Poisons are transformed into sacraments.
A third element of hypnosis is that nothing should disturb the hypnotic trance. Eliminating adverse events achieves this. If things go wrong, the trance can be deepened by persuading patient and doctor that their worsening situation needs more drug, or a new drug – as when suicidality on antidepressants is spun as evidence for bipolar disorder and mood-stabilizers are added.
A Looming Crisis
Regulating medicines was supposed to contain drug companies not medicine. But licensing classes of drugs such as antihypertensives, hypoglycemics, or laxatives captures practice. For instance, there are at least four types of antihypertensive therapeutic principles, all of which on average can lower blood pressure. Each of these drugs has met a target and been licensed to use the word antihypertensive but only one of these principles might work for you or me.
Wanting to lower our minimally raised blood pressure, doctors put us on an antihypertensive without asking what they want this drug to do to lower my blood pressure. As a result, I may end up on three medicines that do not work before a fourth does. Rather than stop the first 3 proven antihypertensives, I risk being viewed as treatment resistant and left on all four drugs. This scenario applies to all classes of drugs from laxatives to antidepressants.
Treating risk factors with drugs that have no side effects, along with a reluctance to make a judgement call and stop ineffective drugs leads to polypharmacy.
The idea that being on 3 or more drugs could bring its own problems began to register around 2000 but can be tracked back to the 1980s when we began to treat numbers, and health services replaced healthcare. Roughly half of us over 45 are now on 3 or more medicines per day, and half over 65 on 5 or more.
Taking medicines to prevent raised blood pressure is quite different to reducing salt intake to do so. Taking a statin is different to stopping smoking. The drugs we are being given can disable or kill in surprising numbers if given on a population basis, and combined with multiple other drugs with which they can interact. The increase in chronic medical disorders might suggest neomedicalism is keeping more of us alive longer but life expectancies are falling in the US and UK.
The financial crisis of 2007 hinged on a financialization driven by neoliberal targets that replaced an exercise of discretion based on political judgements beyond numbers. During the crisis, the Bank of England’s monetary policy committee had to decide whether to raise interest rates in the face of inflation at 4%, which exceeded its 2% target. Increasing interest rates could drag inflation down but risked a recession. A 1% increase in inflation has less impact on our health and wellbeing than a 1% increase in interest rates. Would a quick monetarist reflex kick in or would the Bank act reflectively. Of 9 members, 7 voted to increase rates. Britain went into recession and the Bank was forced to slash interest rates to their lowest ever levels.
Set a target for ambulance waiting times at emergency departments, and management will order ambulance crews to wait at other locations, with an increase in lives lost. Set a body count target in a War, as Alan Enthoven advised Robert McNamara in Vietnam, and armies will shoot civilians.
A pharmaceuticalization crisis was also taking shape in 2007. Since then, life expectancies in the West have stalled or fallen. The failure of our financial services to deliver stability, and a general prosperity is now paralleled by the failure of our health services to maintain the steady improvements in health we enjoyed until recently. Our bodies have been redefined as venues for the consumption of pharmaceutical commodities.
In the financial crisis, financiers and bankers were operating in a state of moral hazard. If dodgy mortgages they sold us went wrong, we lost out but they collected bonuses. They had no incentive to keep us safe. Similarly, when doctors consume by putting drugs in our mouths, there is no incentive now for them to keep us safe. Unlike pilots, who die if we die, doctors, like bankers, operate from a morally hazardous position.
Recognition of medication burdens and the need for deprescribing is growing. But deprescribing takes our doctors and us into uncharted territory. It is intensely individual. It cannot be guided by an algorithm or RCTs. Averages won’t do.
When scientific medicine began in 1800, it was a privilege of wealth to get on treatments to save a life or avoid disability. Progressive parties aimed at leveling up, so that anyone who needed life-saving treatment could get it. But it is fast becoming a privilege of wealth to get off treatments in order to save a life or avoid disability. We need doctors who are not neoliberal but progressive parties stand in the way of us being able to get them.
The application of technologies and techniques through to 1980 was on balance productive and led to an increase in wealth and health. But pharmaceuticalization now has drugs chasing drugs even as life expectancies fall, in parallel with a financialization that has money chasing money as poverty rises.