Biomedicalizing life to regain the hegemony of the health sector
In previous sections we analyzed the strategies utilized by the pharmaceutical industry to regain market positions and leadership in defining the health-ill-care process in the U.S. From the U.S., multinational companies export, through their subsidiaries in other countries, to the rest of the world their new business models and strategies to regain market power. Models and strategies that the companies modify accordingly with the health sector organization and the regulatory environment in each country. Next we will consider some concepts from social sciences theories to better understanding the deep implications of these strategies for the lives of people.
Medicalization is a concept developed in the 1970s to define aspects of life as medical problems previously outside of the jurisdiction of medicine [
30‐
32]. Profound transformations in medicine, facilitated by advances in technosciences, started in the 1980s. To understand these transformations Clarke et al. developed the concept of biomedicalization, based on Foucault's theory of biopower and later developments by Rainbow [
9]. While medicalization focused on illnesses, rehabilitation, and care; biomedicalization focuses on health as an internalized moral mandate of self-control, surveillance, and transformation. Advances in biomedical technosciences, such as molecular biology, genomization, medical diagnostic and treatment technologies, as well as computer and communicational developments created the possibilities for radicalizing the medicalization. Biomedicalization implies a "shift from enhanced control over external nature (i.e. the world around us) to the harnessing and transformation of the internal nature (i.e. biological processes of human and non-human life forms), often transforming life itself" (p. 164) [
9]. Biotechnologies, including drugs and other devices available to patients/consumers, create new biomedicalized subjectivities, identities, and biosocialities. New forms of social relationships are constructed around and through such identities (p. 165) [
9]. Examples of these kind of new forms of social relationships are the social networks using websites, blogs, and other internet forums dedicated to health issues. It is important to remark that these new identities do not always imply the acceptance of the biomedicalized discourses and practices: some of these forum/groups are questioning the moral mandate and other forms of biomedicalization [
33]. The process is not unidirectional and different discourses are created by a multiplicity of individuals and organizations. New organizational developments and regulatory measures could transform the current situation.
The transformation of medicalization into biomedicalization required the confluence of several processes in which the financialization of the health sector had an important role. This process increased exponentially the corporatization of the sector and the commodification of their products at different levels: provision, research, and education. These changes mobilized others stakeholders such as the pharmaceutical industry to develop new strategies. Some of these strategies, as we analyzed previously, included enhancing the direct relationship with potential clients of health products (diagnostic procedures and treatments), as well as health promotion and prevention programs and services.
The technoscientific medicine and its subfields, such as public health, have developed illusory discourses in which death not only could be postponed, but also prevented [
20]. The dream of being eternally young with plenty of energy penetrated all social, gender and age groups. In order to obtain this goal, the message is that people should exercise strict control and surveillance over the risks that could threaten their lives. Moreover, the messages about health-ill-care are presented as social/moral mandates, meaning that if individuals are not proactively controlling their health, the results of their behaviors are at a great cost to society. This goes beyond using specific medical interventions to recover health from illnesses or diseases; it supposes the biomedicalization of health promotion and prevention, requiring the internalization of the social mandate of being healthy, and of surveillance practices at the individual level.
To be healthy in the context of biomedicalization implies that it is each individual's responsibility to test for diseases/conditions, and to utilize drugs, devices, and other technomedical products and services to control the risk of developing diseases or aggravating a condition. The services to accomplish the social/moral mandate include internet tools and other communicational mechanisms that introduce information through the intimacy of personal computer, home entertainment devices, as well as school and other small environments. Individuals are taught about diseases/conditions, how to test for them, and how to access services and products to preserve their health.
In the context of biomedicalization health professionals, in their traditional role as leaders of the process of cure or alleviation of disease, are more and more dispensable for the new business model developed by the pharmaceutical industry. As we described previously the advances in computerization and data banking facilitate the capture, storage, and analysis of enormous amounts of data from individuals. All of this information is utilized to generate messages to reach millions of people interested in health issues. The communication strategies can be developed considering differences in social classes, ages, genders, nationalities, cultures/ethnicities, diseases/conditions/risks, and so forth. There are numerous products and services that the pharmaceutical industry promotes under the concept of "educating people" to prevent the risks of becoming ill that do not require health provider mediation for their consumption. Also, we have described previously that pharmaceutical companies developed tools to teach patients how to direct their physicians and other health professionals to prescribe the desired product. Young people are especially vulnerable to these kinds of marketing messages that promote self-diagnosed and self-prescribed behaviors [
21,
22].
The concept of biopedagogy is also useful to complement the understanding of the analyzed phenomena. This concept, drawing from Foucault's biopower theory, is described by Wright as the normalizing and regulating practices traditionally reserved to schools, but currently appropriated by other learning and communicational spaces, and disseminated more widely through the web and other forms of media [
34]. Biopedagogies place individuals under constant surveillance and towards increased self-monitoring by elevating their knowledge around diseases/conditions, as well as learning how to be healthy. Using Berenstein, Wright states that we are now living in "totally pedagogized societies" where methods to evaluate, monitor and survey the body are encouraged across a range of cultural practices (p.8) [
35].
Individuals are offered a number of ways to understand and change their behaviors, as well as encouraged to take action to educate other members of their families and communities to have healthy lives. Most of the pedagogical tools are created to govern bodies and to provide the social meanings by which individuals come to know themselves and others but not the social-political environment. Moreover the scientific truths are recontextualized in different social and cultural sites to inform and persuade people on how they should understand their bodies and how to live their lives. In this light, health information is developed to facilitate the incorporation of the "outside" world (the social and economic wellbeing of others) into the "inside" (psyche and body) of the individual (p 49) [
36].
In principle more access to medical and health knowledge and information could be considered democratic and it needs to be welcomed. However, in practice we should critically analyze how the data is created, by whom, and what are the interests behind this information market. In addition, the commodification of this process in capitalist societies implies that the access to information is stratified, non-democratic, and differentially affecting social groups and countries. People from the lower classes receive messages reinforcing the social/moral mandate to control their health in order that they do not become a burden to society. For these populations the biopedagogies are implemented at schools, health fairs, community events, and media (especially television). Well intentioned professionals working for public health agencies, schools, and non-governmental organizations also reproduce these messages and biopedagogies without understanding how they operate and the consequences for the biomedicalization of life. People will use their limited income in testing for glucose, cholesterol, high blood pressure, and other conditions and accessing treatments (conventional or alternative) to control these risks. However, as we can observe in health statistics, disadvantaged groups will fail to reach the healthy outcomes of the upper classes, instead they will be left with the guilt of not eating healthy, exercising, and having non-stressful lives. The messages hide that most of the health problems of these groups are not caused by their bad genes triggered by inadequate lifestyle habits, but by the unequal distribution of wealth.
Judicialization of health policies in Brazil: a new path on the creation of the health consumer?
In this section, we will introduce the research that we are initiating in Brazil to investigate if the processes of capturing the demand side are operating through the judicialization of health policies and how they are affecting the capacity of the governmental administrations to regulate the health sector.
The importance of understanding if the judicialization of the health policies in Brazil is another strategy that the pharmaceutical industry is using to regain market power resides in two important facts: 1) in this country health is considered a common good not a private one; and 2) the governmental agencies led the regulatory process in a public-private environment of health care service provision. Brazil approved in 1988 a constitutional amendment declaring that health is a right that the state must guarantee and that each Brazilian has the right to universal and integral access to health care. The constitutional nature of the right to health opens the option for citizens to utilize the judicial branch to demand the fulfillment of their rights when they believe that the constitutional mandate is not followed.
Most of the health care services under the Brazilian Unified Health System (UHS) are offered through an extensive network of public primary care clinics and hospitals, as well as public health programs managed by municipalities. Brazilian citizens also have the right to receive health care services, paid with public funds, through private providers, if the public system does not offer the needed services. In part, because this private-public arrangement to guarantee the constitutional right to universal access to health, the public system is confronting increasing costs not matched by sufficient budget allocations. This obligates governmental administrators to deny access to some health care services and put limitations on the kind of services that can be provided. In particular, these limitations affect specialized and costly treatments, most of which are offered by the private sector. By appealing to the constitutional right, an increased number of individuals are interposing judicial claims demanding that the public system covers health care services that their physicians recommend to them.
Data from the Superior Tribunal of Justice in Brazil indicate that in 2001 only two claims related to health issues were interposed. However, by 2004 the number of cases increased to 672 [
37]. The Health Secretary of Rio de Janeiro started recording the numbers of judicial claims in 1991. Since then and until 1999, the number of cases slowly increased, especially in relation to some diseases. Starting in 2000, the number of cases requiring the Justice to obligate the state to pay for procedures to treat different health problems denied by public medical institutions increased exponentially. At the end of 2002, the Health Secretary counted 2,733 judicial actions against the State of Rio de Janeiro. In March 2006 the number of claims rose to 7,758 [
38].
In the majority of cases, the judges ruled in favor of the citizens, obligating the public health system to pay for the demanded services [
39]. To include more medications, diagnostic procedures, and treatments to be paid by the public system is in accordance with the constitutional rule to guarantee the health right, but it creates a conflict between the health and the judicial systems. Officials from health agencies consider that the judicial branch is assuming authority for decisions that need to be made by health specialists. They complain especially when the solicited medications, treatments, or diagnostic procedures are new, experimental, or off-label indications, implying that the efficacy and safety are not well established.
The judicial branch is playing a more central role in defining the health policies by focusing only on the constitutional right. But this branch of the government may not be considering the powerful actors that could be using the justice system to mandate the inclusion of new treatments to be paid by the UHS. Moreover, increasing the number of services provided with limited funding allocation may threaten the constitutional right itself. Fewer people may be accessing basic needed services, favoring only small numbers of people that receive costly specialized treatments. In addition, if the treatments the judicial system mandates the UHS to pay are predominantly those offered by private providers, the public system is subsidizing them, when public hospitals and clinics are confronting increasing budgetary restrictions. In fact, the judicial claims appear to benefit more the middle and upper classes. A study analyzing 2,927 judicial claims demanding the state of São Paulo to pay for medications not covered by the UHS, shows that 73% of claimants reported that they live in high and middle income neighborhoods, while only 27% live in low income areas. Moreover, 74% of the cases were represented by private lawyers while only 26% were represented by public defenders [
39].
These are the nature of the problems that our team is starting to investigate in Brazil. Our empirical work will focus on understanding the implications for regulatory agencies of the judicialization of the health sector, as well as the role that the medical industrial complex plays in this process. We are also studying if the Brazilian pharmaceutical industry is adapting the strategies observed in the U.S. which turns users/patients into consumers by marketing new treatments, e.g., those approved but not covered by the public system, off-label indications, or not approved at all by the regulatory agencies in Brazil. In situations like Brazil where health is a right guaranteed by the constitution, unneeded consumerism of health services promoted by the medical industrial complex may be seriously threatening the stability and continuity of the public health care system, as well as increasing health inequities. We are only at the beginning of this research agenda that will provide important information to improve the regulation of the health sector and demonstrate the need for a close dialogue among branches of the government.