Opinions of a Wolf

Summary:
Written by a professor of Anthropology, this book explores the interaction of the cultures of medicine, pharmaceuticals, and public health and how they have impacted the modern Western perception of what constitutes health and what makes a person count as healthy.

Review:
I was immediately drawn to this anthropological exploration of what has impacted the modern perception of health and requested it on NetGalley.  Although the book can sometimes feel a bit long and repetitive, the information it contains is an even-handed look at the reasons behind so many people in the West being put on preventive prescription medication.

Since this is written by an Anthropologist, not a journalist or a doctor or pharmaceutical representative, it has neither an expose feeling to it nor a particular slant.  It’s clear that the author originally was just looking at the culture surrounding healthcare, and the evidence led him down this path.  Anyone who is familiar with Anthropology knows that Anthropologists are trained to attempt to avoid biases and just report what they see.  Of course, everyone is human, and I definitely think that by the time Dumit finished his research he has formed an opinion that the reader can observe, however he does quite a good job of just presenting the facts.

The book is divided into six chapters, plus an introduction and conclusion.  The six chapters are: responding to facts, pharmaceutical witnessing and direct-to-consumer advertising, having to grow medicine, mass health: illness is a line you cross, moving the lines: deciding on thresholds, and knowing your numbers: pharmaceutical lifestyles.  The book thus moves from the culture of facts and how we respond to them, to the business of pharmaceuticals, to how public health has impacted how we treat individual health, to how the individual health care consumer responds to the information they hear from all sides.  Again, all of this is presented from an anthropological perspective.  If a reader has not read an anthropology-research based book before, the way in which Dumit looks at the information may be a bit confusing or surprising at first, since it is more about culture, which may not be expected at first, given the title.  However, the second chapter helps this perspective make sense, so even a reader new to this perspective will most likely be able to get into it.

What inspired Dumit to conduct this cultural investigation is the sheer number of drugs the average American is prescribed.

The average American is prescribed and purchases somewhere between nine and thirteen prescription-only drugs per year, totaling over 4 billion prescriptions in 2011 and growing. The range is wide, however, and many people are prescribed few or no drugs each year. (loc 100)

What Dumit’s investigations revealed was a cultural shift from treating an illness after it negatively impacts a person’s life to attempting to prevent illness.  Whereas individual doctors may prefer prescribing lifestyle changes (work out more, eat differently, stress reduction), some doctors prefer being able to simply prescribe a drug and some groups of patients may prefer to keep their lifestyle and take a preventative drug.  Similarly, the pharmaceutical industry sees preventative drugs that are taken by large groups of people with risk factors as a more monetarily sound investment than generating drugs for an illness that would be taken one-time or simply for the duration of the illness or just from the time of diagnosis to the end of the person’s life.  Preventative drugs are prescribed to people who have risk factors for developing an illness, and they then must be taken every day.  At the same time as these situations have developed, public health, since the 1970s, has started looking at groups of people at risk for developing a disease that would have a negative public health impact and advising that people with these risk factors be treated to prevent the disease from ever occurring.  All of these factors have created the environment in which we now live in the United States where people who are not yet sick are still taking multiple prescription drugs to prevent their getting sick, often in spite of dealing with side effects.

I will now discuss the elements of this overarching concept that I found most interesting.  The book contains many more facts and information than this, and if you find any of this at all intriguing, I highly recommend you pick up and read the whole book.

First, there’s the fact that clinical trials are extremely expensive to produce.  Pharmaceutical companies thus are most invested in clinical trials whose results would indicate treating the largest number of people for the longest amount of time and, perhaps most importantly, only for those people who are able and willing to pay for these drugs.  (loc 145)  What this means is that illnesses that only a small percentage of people have are not getting clinical trials for drugs.  Similarly, illnesses that a lot of people have but most of those people cannot afford to pay for the drugs, such as tropical diseases prevalent in African countries, also are not getting clinical trials for drugs to treat them.  The pharmaceutical companies are businesses that are interested in making money, not in improving the quality of life for everyone on the planet.

Marketers want to maximize the number of prescriptions in order to maximize profits. They see clinical trials as investments whose purpose is to increase sales of medicines. (loc 1415)

I also found the question of what constitutes health and how that has changed over the years fascinating.  Originally, people generally only came to the doctor if they felt sick or as if something was off.  We are now encouraged to engage in preventative care.  How this impacts how we perceive of health is summed up well here:

We have a new mass health model in which you often have no experience of being ill and no symptoms your doctor can detect, but you or your doctor often discover that you are at risk via a screening test based on clinical trials that show some efficacy of a treatment in reducing that risk; you may therefore be prescribed a drug for life that will have no discernible effect on you, and by taking it you neither return to health nor are officially ill, only at risk. (loc 195)

Tied into this idea of risk factors being treated as illnesses and thus healthy people being treated as not healthy is the idea that outliers, variations, and things that are simply socially undesirable can often be reclassified as illness, particularly if doing so means that the pharmaceutical companies will make more money. (loc 1079)

Third, I was intrigued by the discussion on the public health model.  Public health seeks to reduce illness in the population as a whole by treating those with risk factors, but also by treating however many it takes to reduce the occurrence of illness.  An example of a community-wide public health intervention is adding fluoride to the public drinking water.  This is done to everyone in the hopes that it will help prevent cavities, regardless of the actual individual risk factor for developing cavities.  A public health intervention that is done only to those with a risk factor is taking statins to lower cholesterol.  This is recommended for individuals whose cholesterol falls in a certain range, but there is no exact science in creating that range.  In fact, the cholesterol range is frequently lowered, putting more and more people on statins, even if only a small percent (less than 10%) of people are actually helped by being on these statins.  The question Dumit raises in this discussion is:

At what point are public health officials justified in intervening on a community-wide basis to protect a group of people who are not all equally at risk and who might not want to be protected? The push and pull of paternalism versus autonomy is a constant refrain in the field. (loc 1667)

Of course, the pharmaceutical companies want more and more people included in the risk factor, they even would probably be fine with everyone being on statins as a community-wide public health intervention, since this increases their sales.

Finally, I was also interested in how the book examines how the average patient population responds to all of this information about risk factors and preventative drugs and medicine and constant flow of health information.  Dumit divides the response to this into three general groups: “expert patienthood, fearful subject of duties, and better living through chemistry.” (loc 2842)  The expert patient is like the teacher’s pet.  They know all their health numbers and risk factors, listen to their doctors, take anything prescribed, and advise others to do the same.  These guys are the health seekers.  The second category, fearful subject of duties, is motivated by avoiding illness, not by seeking health.  The final category of patient is the one I alluded to earlier.  These folks won’t change their lifestyle in response to risk factors, but will instead request a pill so that they can continue living how they prefer.  Which category do you think you fall into?

I think the book in general could be a bit better organized.  My notes, although taken linearly, read as a bit disjointed, with some jumping around among different ideas.  The overarching concepts are not laid out as clearly and succinctly in the book as they are in my review.  Similarly, some concepts can be repeated a bit too often, leaving the reader feeling like they’ve read this before.  Also, sometimes the book delves a bit too deeply into anthropological concepts and methods, given the fact that it is presented as a book for a layman.  Finally, I feel the title of the book is a bit too click-baity.  It reads as if it was written to sound much more controversial and attacking of the pharmaceutical industry than the book itself actually is.  The title reads like the book will be a heavy-hitting expose, when really it is an even-handed piece of anthropology work.

Overall, this book will appeal to anyone interested in how the United States health care culture has evolved to the point it is currently at in regards to prescribing so many drugs.  The reader does not have to be a scientist or involved in medicine to understand the book, although portions of it may feel a bit repetitive or overly technical at times.  Although the book could be a bit better organized, overall it presents a clear look into the culture of drug prescription in the United States, and I recommend it to anyone interested in that topic.

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4 out of 5 stars

Length: 280 pages – average but on the shorter side

Source: NetGalley

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