Pharmaceutical Technologies and the Management of Biological Citizens in Chile
The hospital’s head psychiatrist, Dr Muñoz,1 held appointments with patients in his office, a small, ten-foot by twelve-foot rectangular space, crowded with furniture.2 The psychiatrist’s desk had two chairs on either side. The cabinets mounted on the wall at eye level behind the psychiatrist’s desk housed multiple books about psychiatry and mental health, including a copy of the Diagnostic and Statistical Manual, 3rd edition.3 An entire cabinet space was heaping full with muestras, boxes of free samples of various drugs from pharmaceutical companies which had been haphazardly tossed in upon receipt – Sertac (sertraline), Arilex FT (aripiprazole), Traviata XR (paroxetine), Noptic (eszopiclone) and Aceptran (clonazepam) were the most recent arrivals. A calendar on the bookshelf advertised Cymbalta (duloxetine manufactured by Eli Lilly) and on the psychiatrist’s desk was a calendar for Aroxat (paroxetine produced by GlaxoSmithKline). The desk featured a laptop computer set up next to a box of tissues advertising for Wellbutrin (bupropion manufactured by GlaxoSmithKline) and coasters displaying Pfizer’s logo. Among the seemingly disorganized piles of paper on the right side of the desk were a paper brochure from Janssen-Cilag about Attention Deficit/Hyperactivity Disorder and another brochure underneath from Laboratorios Andrómaco. A year-at-a-glance calendar on the back of the door came from Globe Chemicals Company in Germany. Each of these items had been gifted to the psychiatrist during regular visits from representatives of pharmaceutical companies. It was within these walls that patients would come, sit down and consult with Dr Muñoz, often revealing significant or traumatic life experiences, in hopes of finding some resolution to their suffering within their fifteen- to thirty-minute appointment.
Pharmaceutical intervention for illness, disease and disorder is not a new phenomenon, although its increasing presence in healthcare represents part of the changes in health, illness and medicine related to biomedicalization (Clarke et al. 2010). Biomedicalization is a series of processes leading to an intensification of health-oriented discourses, sciences and technologies, where new technologies are enabled to compartmentalize pieces of the body on smaller and smaller scales to pinpoint the place of and intervene against illness. Additionally, biomedicalization is attentive to how more human conditions are coming under the medical gaze, managed through advances in technoscience such as pharmaceutical interventions that act upon chemical compounds within a person’s body. Pharmaceuticalization is a more recently explored trend within medicalization more broadly, wherein drug treatments are deemed necessary or considered as best practices in the management and resolution of illness, disease and disorder (Bell and Figert 2012a).
Scholars have argued that societies structured around responsible management of population health through the use of medical treatments will lead individual people to interpret their problems through the lens of biological ailments and to demand care for their ailments from the government, a concept called biological citizenship (Petryna 2002, 2004; Rose and Novas 2005; Rose 2007). This chapter evaluates the shape of biological citizenship within a specific Chilean context; drawing from empirical examples, I propose a modified, more dynamic vision of biological citizenship.
Mental Illness and the Pharmaceutical Market in Chile
Narratives of global mental health have touted Chile as a success story. Part of the cited success of Chile is the increase in the number of people treated for depression over time, from around 29,000 in 2001 to over 275,000 in 2009 (Minoletti, Rojas and Sepúlveda 2011). From 2004 to 2007 the number of new patients seeking treatment each year for mental illnesses went up almost 350 percent, primarily because of depression (Minoletti, Sepúlveda and Horvitz-Lennon 2012). Global mental health researchers and the World Health Organization (WHO) anticipate that through the nation’s involvement in various mental health initiatives, including expanding access to psychiatric services and treatment within primary care, psychiatric knowledge would “trickle down” to the level of the general population.
Explanations for this seeming explosion of depression diagnoses and prevalence in Chile are located within recent developments in healthcare in the country, which is the other component considered successful in narratives of global mental health. In 2001, the national program for depression was unveiled, and in 2005 the new national healthcare program (AUGE/GES, Regime of Explicit Health Guarantees) included a pilot program for depression that was officially incorporated in 2006. AUGE originally provided free or low-cost treatment for four of the most common mental illnesses: depression, schizophrenia, alcohol and drug abuse.4 Antidepressants are offered by the public health system as part of AUGE, most of which are given a grade of “A” by the Ministry of Health’s Clinical Guide for the Treatment of Depression.5 In light of these recent developments in healthcare coverage, it may not be that the number of people with depression increased so suddenly, but that the provision of mental healthcare services for low or no cost has made treatments more accessible, especially among the poor. In the context of a population with an average expendable income of just over US$11,000 per year (OECD 2014), for poorer families the US$75 sometimes required for hospitalization would still be quite expensive.6
Even before AUGE was in place, the use of antidepressant medications in Chile had skyrocketed over 470 percent from 1992 to 2004 (Jirón, Machado and Ruiz 2008). In 2009, the private sector had pharmaceutical sales over US$1 billion while the public or institutional market reached US$400 million (Hartwig, Quirland and Dickens 2009). By 2012, the retail pharmaceutical market in Chile reached approximately US$1.5 billion (CENAFAR 2013). The pharmaceutical industry is competitive in Chile, with local laboratories such as Bagó and Royal Pharma accounting for 58 percent of private sector sales (Hartwig et al. 2009).
On average, 55 percent of Chileans’ healthcare costs for any diagnosis are for pharmaceutical treatments (CENAFAR 2013). Recent political developments are shaping the current pharmaceutical context in Chile, as there are commitments to enable lower prices of drug treatments (CENAFAR 2013) and a bioequivalents (generics) campaign to spread the word about cheaper and equally effective, chemically identical drugs (www.bioequivalentes.cl/home.html, accessed May 5, 2014). The Ministry of Health is working on a Pharmaceuticals Law to guarantee the availability of generic pharmaceuticals, which has been estimated to potentially save Chilean families over US$3,000 per year and over US$300 per year on antidepressants specifically (Rojas 2013).
During my six months of fieldwork in the clinics, I observed that representatives from various pharmaceutical companies would come to speak with the doctors nearly once a week. The company representatives would come in between outpatient consultations for a brief visit of no more than five minutes, sharing a pamphlet about a new drug, giving Dr Muñoz (the hospital’s head psychiatrist) promotional merchandise such as highlighters or chocolates and inevitably ending in leaving some samples at the office. The pharmaceutical samples left at the hospitals made it possible for mental health professionals to provide free treatments to a financially strapped patient base, especially for cases where the AUGE program did not provide coverage. The heavy presence of pharmaceuticals within the space represents a new form of pharmaceutical governance enabled by neoliberalism (Biehl 2006); the state program governing wellness through the provision of mental healthcare involving low-cost or free access to antidepressants is accompanied by the promotion of self-reliance and responsibility in using them to achieve wellness.7 This could be considered pharmaceuticalization of psychiatric care. That is, antidepressant medications were strongly promoted in the space and were relied upon as the primary means of care for depression; all other treatments, such as psychotherapy, supplemented pharmaceutical therapies. A turn towards pharmaceutical solutions for illness, the marketing and promotion of such solutions, along with physician and government support of pharmaceuticals have all been documented as processes of pharmaceuticalization (Abraham 2010; Busfield 2010).
Studies in biomedicalization posit that as a result of society’s intensifying focus on health through technoscience both knowledge and identities are transformed (Clarke et al. 2003, 2010). A key concept for understanding this transformation is biological citizenship, originally theorized by Adriana Petryna (2002, 2004). Biological citizenship represents an identity produced when individuals come to understand their problems in terms of health and illness and to urge the national government to provide care for these problems. Rose and Novas (2005) and Rose (2007) further theorized biological citizenship as an extension of biopolitical governance. That is, within a biopolitical system, society is managed with an emphasis on maintaining the health and well-being of the population, with health defined simultaneously in economic, political and scientific ways. Biopolitical systems and biomedicalization encourage individuals to seek the care of trained professional healthcare providers as experts who have been empowered as knowledgeable about health (Foucault 1990, 2003; Rabinow and Rose 2006).
Biopolitics goes beyond management of society and into a way of socializing individuals how to think of themselves. In biopolitical societies, individuals are encouraged to regulate themselves in accordance with the good of the whole. It is through being socialized in this system, Rose (2007) theorizes, that biological citizenship takes shape. Rose’s (2007) conception of biological citizenship as the outcome of socialization within a power structure utilizing biopolitics means that individuals within such a context will express their concerns in terms of problems in biological processes that are interpreted as illnesses. As citizens, people would also make demands upon the state as the primary agent of governance to intervene on behalf of the population’s health. The experiences of two patients, Gloria and Pamela, as presented in the next section, demonstrate how reliance upon pharmaceutical interventions in the AUGE program helped to shape biological citizenship in the Chilean context. One effect of the state’s policies for coverage of psychiatric care is the creation of a unique biological citizenship.
Diagnostics and the Dispensation of Medications
Gloria was referred to the inpatient clinic directly from an appointment at her neighborhood’s consultorio in Las Condes. She stood approximately five feet, ten inches tall in knee-high black boots with black tights, and a purple and blue slinky dress that stopped short of her knees. Her wavy, black hair was cut short with wisps falling down the back of her neck. Although Gloria had accomplished a postsecondary technical degree, she was not working at the time she entered the inpatient facility. That day, she spoke openly and almost conversationally about the recent events in her life. Her father had been very sick, and died in her arms only five months before. She had been wanting to commit suicide, with a plan to throw herself in front of a subway train while holding her son in her arms. She explained to the head nurse and occupational therapist that she had previously been diagnosed and hospitalized, and pharmaceutical interventions did not work for her. “Drugs are almost useless,” she said, before saying that she wanted electroshock therapy. The intake interview then ended abruptly, and after the occupational therapist escorted Gloria out of the room, the head nurse asked me what I thought about the new arrival. “It is interesting that she wants TEC [terapia electroconvulsiva, electroconvulsive therapy],” I said. The head nurse responded that it was common that patients ask for electroconvulsive therapy because of the “show” of it, going to a different area of the hospital for the sessions, having to sign forms and being informed about a unique, exotic treatment. For some patients, she said, the spectacle alone worked great. “So it’s more a placebo effect?” I asked. “Yes, the placebo effect works wonders,” she responded.8
Gloria’s connection between negative emotional states and desire for suicide with a globally recognized, official psychiatric diagnostic label and her knowledge of acceptable treatment options within psychiatric standards and healthcare service capabilities demonstrates the co-constitution of new forms of knowledge, technoscientific interventions and services characteristic of biomedicalization (Clarke et al. 2010). Notably, her strategies exemplify a key component of biomedicalization, to optimize her performance.
Gloria’s insistence on the necessity of biomedical intervention for her survival along with her knowledge of particular kinds of interventions as ineffective for her represents a level of transformation of her own identity and subjectivity as part of the processes of biomedicalization of depression in the context (Clarke et al. 2010). Gloria had familiarized herself, perhaps through previous experiences in mental health treatment, with the languages of biomedicine as the socially and medically acceptable mechanisms for recovery. Her knowledge of possible biomedical treatments works simultaneously to produce personal empowerment as her own expert, to become fluent in speaking the same languages as care providers and to demonstrate that she is a proper biological citizen who speaks the dominant language of health and personal responsibility for her own health. Gloria could potentially find validation by aligning her view of possibilities with medical professionals’, although as this example shows Gloria was discredited due to her uncredentialed, patient status. The head nurse’s seeming dismissal of Gloria’s request for electroconvulsive treatment asserted a classic power differential between patient and provider. In biopolitical terms, this interaction indicates that from the expert perspective it was really the provider, rather than the patient, who knew best which intervention to utilize, and that the best intervention would include pharmaceuticals.
In the following Monday’s rounds of interviews the entire staff arranged to speak with Gloria. After the weekend in the hospital, she looked tired as she shuffled slowly into the staff room with her eyes slightly closed. Gloria sat down and the interview commenced, with four medical students and the head psychiatrist listening attentively. Gloria described herself as overly demanding and perfectionistic. While she was employed, she would often work from 8:00 am to 11:00 pm instead of 6:00 pm out of sheer desire for her work. Gloria first experienced depression six years earlier, at age thirty, when her brother had an accident and was in a coma for twenty days. The same year she gave birth to her son. During her pregnancy, she had problems with her partner and although she broke up with him, he continued to bother her. Gloria’s father, she said, died recently of a lung infection and had advanced Parkinson’s disease. His passing greatly affected Gloria, even though during her childhood he drank alcohol often, causing her to lose trust in him as a provider, meaning she had to mature early. She came to the hospital the past Friday because she found herself unable to cry and felt she had a depression she could not get rid of. Gloria had tried twice previously to kill herself by taking seventy pills and cutting her arms. This time, she wanted to throw herself in front of the subway train with her son, because she could not bear the thought of her son being on his own after her suicide. It would be better, she reasoned, if he died then too. Killing herself, she told the doctors, would solve her problems without bothering anyone. Gloria said she didn’t want to be hospitalized a long time; she just wanted electroconvulsive therapy and to go home to her son, whom she missed terribly. “I want to stabilize myself quickly, to be with him.” Over the course of the weekend she was prescribed and began taking five pharmaceuticals, including risperidone, clonazepam and paroxetine. She reported that her body was shaking a lot, and she was not sure why. “I needed to hospitalize myself but I didn’t want to just take pills,” Gloria said. “I want to put my emotions in order and I want to be able to withstand more.”
When I was able to interview Gloria about her diagnosis she stated:
Depression is a, for me, is a state in which one enters, in which one needs tranquility, needs therapy, needs value, a lot of value as a person, because that causes anxiety and much shame. That is super important. It’s when one reaches the bottom, when one reaches the bottom, and has, have a very large anxiety in the soul [from which] one cannot move forward alone. You have to do it with someone else. To help yourself … They say the causes are genetic.
What would you tell someone who has depression?
That it’s an illness, so negative, so negative, but that you have to ask for help. Ask for help. Ask for help because many people who develop depression don’t ask for help. That they see to solving their problems because that will happen with time. Get treatment whether in short or long term but so they can get a solution to their problems. [Help means] with doctors, or psychiatrist, or psychologist, that are really important, like psychotherapy, and that you take fármacos [medication/drugs].
Gloria’s account points to several thematic elements that swept across other patients’ descriptions of their experience as well as their explanations for depression, including reliance upon medical doctors, psychiatrists and psychologists as mental health experts and the seeming contradiction between perceived causes and suggested interventions for depression.
Outpatient appointments and inpatient interviews with mental health providers were similar to Gloria’s experience: patients would come in to discuss what had been bothering them, describing symptoms and the environmental or social circumstances around them. Care providers in both settings swiftly made diagnostic decisions based on the patients’ symptom complaints, the severity of those symptoms (how much the symptoms impact people around the individual, or the individual’s social interactions), and any response to previous drug treatments as indicated by whether the original symptoms and severity persisted or worsened. In outpatient appointments, new patients would get detailed instructions on how much and how often to take the drug they were prescribed – take one in the morning, one in the afternoon, and one at night, for example – and returning patients would discuss how well their current medication seemed to be working for them, often to have their dosages or schedules changed.
The combination of symptoms, severity and response to any previous medication were not considered in isolation. Often, psychiatrists would consider the patient’s ability to pay for medication, as few specific drugs were covered by the government program for depression. One patient from a lower socioeconomic class could not afford Wellbutrin medication. “It will work best for him [of options available], but it is expensive,” Dr Muñoz explained. Whereas most samples are meant to last perhaps a few days, the psychiatrist gave all four boxes of Wellbutrin he had to the patient, to last for the month. Pharmaceutical decisions were made by considering symptoms, their severity and the individual’s response to previous medication, all in combination with the economic constraints of the individual as demonstrated through this next example.
Pamela came to the hospital after having been referred to Dr Muñoz through her comuna’s mental health center. At thirty-seven, she was separated from her husband and had two children aged ten and fifteen. Pamela did not like that her daughter had gone to live with her father, and Pamela reported that she often felt anxiety about her situation in life and specifically about her children. The head psychiatrist stopped the interview with Pamela and turned to face me. “You see,” he said, “She does not have depression. But I am diagnosing her with depression for administrative reasons so she can get the drugs for free, because otherwise they are not available to her.” Pamela nodded along as the psychiatrist spoke. He explained that the same drugs to treat depression that were available through AUGE would help Pamela, although they were not as beneficial as some pharmaceuticals manufactured explicitly for anxiety. The psychiatrist turned back to Pamela and to his desk, and began filling out a diagnostic processing form for depression, to allow Pamela to leave momentarily with a prescription to fill for free at the hospital’s pharmacy.
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