Medicalization: Benefit to Health or Medico-Scientific Colonialism?

Alarryyk

November 30, 2006

This paper considers the concept of medicalization within the context of several themes: 1) the human ‘moral experience’ of health and illness; 2) the scientific construction of disease; 3) social control of human patterns of behaviour; and 4) human rights-based approaches to health. At stake in the concept of medicalization are competing viewpoints about the essence of human existence. Medicalization refers to the process of everyday activities and behaviours becoming ‘pathologized’ and stripped of their contextual meaning by medical or psychiatric diagnosis and classification (Kleinman and Benson, 2006). It is important for social researchers to critically examine the power-relations of the key stakeholders of the process of medicalization in the context of globalization. Ballard and Elston (2005) argue that there is room for resistance and a possible ‘demedicalization movement’ against the imperial tendencies of the global health industry but such arguments must be examined in terms of results. The World Health Organization (2001) predicts a coming global ‘crisis of mental illness’ comprised of what are known as ‘common mental disorders’ and the potential for the disempowering of billions of sufferers through medico-scientific colonialism exists beside the possibility of social change.

Introduction

We are at a time in human history when tough decisions need to be made to ensure the continuing survival of our species and our ecosphere. This is a time when scientific knowledge and technologies offers the promise of creating humane living conditions for all and offer the release from needless suffering for billions. The problem is that the ownership of scientific knowledge and technology are in private hands—a fact that undermines its ability to affect positive social change. Medicalization, or the conceptualization of human life processes in medico-scientific terms, is a case in point. On the one hand, the medico-scientific identification and classification of human health/illness could greatly benefit aging populations in the industrialized Western nations and may help to improve life expectancy and quality of life in underdeveloped regions; however, on the other hand, since medico-scientific knowledge about human health/illness and life processes is privately owned, it must serve as a means to an economic end for the global health industry (McMichael, 2004). The challenge facing humanity with regards to medicalization, and the ‘commodification’ of human health (Coburn, 2006), is not to be fooled by human-rights discourse that advocates health care restructuring across the globe. Such restructuring guarantees easier access to new markets for the global health industry but guarantees nothing in terms of improving population health.

Health, Illness and Human Experience

The ‘medicalization of everyday-life’ strikes at the heart of our conceptions of what it means to be human. Purportedly objective medico-scientific discourse of subjective states of mind and body tend to alienate human experience within categorical descriptions and definitions. Kleinman and Benson (2006) argue that the patient’s ‘moral experience’ of health/illness has to be considered in medical diagnosis and treatment (Kleinman and Benson, 2006). At issue is that folk/cultural/ethnic knowledge and experience of health and illness can be a key part of the construction of meaning by a group or society of human beings. Whereas the universal, rational categories of disorder and illness exemplified in such compendia as the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association (APA) can erase such meaning by considering biology outside the social, cultural and spiritual context in which the patient exists. The definition of mental disorder contained in the DSM-IV-TR is illustrative of how the APA has tried to remain as objective, detached and a-theoretical as possible while simultaneously casting a shadow over their entire enterprise:

“[mental disorder is] a clinically significant behavioural, psychological syndrome or

pattern that occurs in an individual and that is associated with present distress (e.g. a

painful symptom) or disability (e.g., impairment in one or more important areas of

functioning) or with a significantly increased risk of suffering death, pain, disability, or

an important loss of freedom. In addition this syndrome or pattern must not be merely an

expectable and culturally sanctioned response to a particular event, for example, the death

of a loved one. Whatever its original cause, it must currently be considered a

manifestation of a behavioural, psychological, or biological dysfunction in the individual.

Neither deviant behaviour (e.g. political, religious, or sexual) nor conflicts that are

primarily between the individual and society are mental disorders unless the deviance or

conflict is a symptom of a dysfunction in the individual, as described above”

(DSM-IV-TR, 2000:xxxi).

The APA’s definition ignores causal factors as indicated by the sentence that starts ‘whatever its original cause’ and mentions culture only in passing without offering a definition. Moreover, the APA seems to ignore its own cultural bias when its DSM-IV checklist diagnoses a major depressive disorder as starting after two weeks of grieving (DSM-IV-TR, 2000:354). Western societies like the US and Canada may have developed a cultural expectation of mourning as taking place for no more than two weeks, but many other societies and cultures can have mourning periods that last years. As Kleinman and Benson (2006) argue: “Instead of a checklist, what clinicians want to get at in the explanatory models is what really matters for patients, their families, and for the clinician as well: a combination of cultural and personal meaning” (Kleinman and Benson, 2006:835). Seen in this light, even suffering can be valuable and has meaning. Moreover it should not be immediately dulled by pharmaceutical intervention, according to a checklist, but used instead as an opportunity to reflect on the life processes of the individual vis-à-vis society. For example, if a widow in Latin America mourns longer than two weeks over her husband’s ‘disappearance’ it does not follow that the problem is with her individual biology. Rather, her grief could better be explained as resulting because of living in a society that permits its citizens to be eliminated for political reasons. Yet if she is individualized and categorized and given a diagnosis of major depression, the opportunity to critically examine social factors is obscured by her ‘responsibility’ for her defective biological processes.

Scientific Construction of Disease

In addition to diminishing cultural meanings of health/illness, medico-scientific discourse about life-processes tends to increase the overall amount of illness/disease or disorder by creating new and ever increasing typologies. The problem begins with the mediation of human experience by categories of rational science (Foucault, 1965), is compounded by the commodification of health and health-services (Coburn, 2006), and is articulated by trans-national pharmaceutical and insurance companies, the medical and psychiatric professions—the most powerful stakeholders in the global health industry (Oldani, 2004). The individual with a health concern is recast into a ‘consumer’ of health related knowledge, products and services rather than retaining her identity as a human with some interference of wellbeing. The health industry expands its markets by the creation of new illness/disorder categories (Moynihan and Cassels, 2005). Two examples are shyness and women’s menstrual mood swings. Shyness became social anxiety disorder (SAD) and menstrual mood swings became a dangerous disorder known as pre-menstrual dysphoric disorder (PMDD) (DSM-IV-TR, 2000). Clearly people had been dealing with these as ‘normal’ life challenges for millennia but within the last 20 years these life processes have been medicalized and treatments are now available by prescription.

Some theorists argue that this conception of humans as “thralls” to a monolithic health industry is simplistic and one-sided (Ballard and Elston, 2005). Yet as Marx (2002) argues: those who control the means of production also control the means of production of knowledge. The ‘resistant’ consumer cannot control the production of knowledge about her own ‘condition’ and can at best influence how the discourse takes place with involvement in lobby groups and activism. The actual knowledge is produced by health industry primary stakeholders and, despite the consumer’s possibility of access to new services or acquisition of a Parsonian ‘sick role status—which offers some reduction in personal responsibility in exchange for compliance with treatment—these ‘gains’ require a ‘net-loss’ in the self-determination of the individual. At best these strategies should be seen as negotiations regarding the terms of compliance with the social control of medicalized deviant behaviour.

Social Control of Patterns of Behaviour

The medicalization ‘movement’ is increasing with globalization. In a 2001 report entitled Mental Health: New Hope, New Understanding, the World Health Organization argues that by the year 2020 the world will be host to a ‘global crisis of mental illness’ comprised largely of depression and anxiety disorders (WHO, 2001). As the process of ‘economic modernization’ or ‘development’ leaves a trail of broken and failed states in its wake, potentially billions of people are now ‘at risk’ of developing a mental illness. The WHO’s (2001) report opens with a rejoinder and reminder to all nations about the human right to health including ‘appropriate’ mental health care. It offers an analysis of the current conditions of health care systems globally and makes policy recommendations that advocate stockpiling psychotropic medications—to combat the crisis of mental illness—creating more treatment facilities and advocating the institution of national mental health policies globally (WHO, 2001). Since 2001 the WHO’s policy and health care restructuring goals have been facilitated by attaching them to IMF and WB loans as borrowing conditions and national health policies must satisfy WTO stipulations (Gordon, 2004).

The rapid change of living conditions associated with globalization and its increasingly neo-liberal policies creates conditions where a majority of humans may be depressed or anxious about their future. Add to this the projected release of the fifth edition of the APA’s DSM in 2010 and its expected huge increase in disorder categories and what emerges is a tremendous opportunity toward increased profitability because of new markets and infrastructure for the global health industry. An attendant concern is the potential for the reshaping of human lived experience on a massive scale. The DSM reinforces individual responsibility for health/illness and shifts the focus away from social conditions and, as mentioned above, obscures causality, making it easier to treat a dissatisfied population with psychotropic medication rather than admit the possibility that social relations need to change. A marginalized population of depressed and anxious persons may find it much harder to offer an organized resistance to globalization due to having their concerns or symptoms medicalized. Medicalization is part and parcel with the commodification of all areas of human existence inherent in the economic globalization project.

Ballard and Elston (2005) point to the ‘demedicalization’ of homosexuality in the 1970s as evidence that medicalization may not be proceeding as “inexorably and inevitably” as previous theorists believed and offer it as an example of resistance (Ballard and Elston, 2005:239). However, these theorists do not enter into a discussion of the process of medicalization and psychiatrization involved in the evolution of the DSM. Although homosexuality was dropped as a disorder category in the DSM-III, largely as a result of social pressure from the gay liberation movement, the new manual also bowed to pressures from the global health industry (Kutchins and Kirk, 1997). The review board of the DSM is made responsive to health industry pressure by its admission of MDs and professionals who have known ties to pharmaceutical trans-nationals and also to insurance and government interests (Kutchins and Kirk, 1997). The DSM-III featured a new diagnostic system and classes of disorders that lent itself better to the needs of insurance companies—in 1980 the major funding bodies of mental health care in the US—and practitioners who were faced with a broader spectrum of complaints due to community versus institutional care (Kutchins and Kirk, 1997). The liberation of homosexuality from its previous status as a psychological or behavioural disorder came at the expense of other previously socially inert categories: “the greatest expansion occurred among the children’s disorders, an area relatively neglected previously compared to adult disorders” (Kutchins and Kirk, 1997:45). Additionally, unlike homosexuals most ‘disordered people’ do not exist as, or indeed think of themselves as, a community thereby limiting their ability to resist medicalization. As Zola (1993) argues:

“While most minority group members grow up in a recognized subculture and thus develop certain norms and expectations, people with chronic diseases and disabilities are not similarly prepared. The nature of their experience has been toward isolation. The vast majority of people who are born with or acquire such conditions do so within families who neither have these conditions nor associate with others who do. They are socialized into the world of the ‘normal’ with all its values, prejudices, and vocabulary. As one generally attempts to rise out of one’s status, there is always an attempt to put this status in some perspective. The statements that one is more than just a Black or a woman, etc., are commonplace. On the other hand, where chronic illness and disability are concerned, this negation is almost total and is tantamount to denial. Proof of successful integration is embodied in such statements as ‘I never think of myself as handicapped’ or the supreme compliment, ‘I never think of you as handicapped’” (Zola, 1993:167).

So unlike many disordered people, the individual homosexual found it liberating to discover that being gay in-itself is not grounds for depression, anxiety and isolation due to the discovery of a vocal community of like-minded people. Through activism the gay community de-listed their sexual preference from the DSM and constructed it as a lifestyle choice. But the discovery of a gay community was also an economic opportunity for the health industry because although homosexuality was delisted as a deviant behaviour, it is now a medico-scientific category with its own attendant market. In the case of people with depression or anxiety disorders, the likelihood of successful resistance movements is slim due to their tendencies to isolate themselves and the deterioration of socialization skills due to isolation—depression and anxiety are not lifestyle choices.

Ballard and Elston (2005) claim that the medicalization process is multidirectional and that the patient or consumer has a hand in driving the process by creating need for categories and treatments, as in the case of chronic fatigue syndrome (CFS) (Ballard and Elston, 2005). While coordinated action of a community of CFS sufferers may have resulted in recognition of CFS as a disorder, the ‘consumer’ is still limited to the official narrative of the disorder and the ‘approved treatment’ if she wants access to any benefits that may be attached to disorder/disease or sick-role status. If she would prefer to treat her CFS with meditation and exercise (i.e. choose her lifestyle) rather than with painkillers and anti-depressants it may be hard for her to convince a doctor, acting as gatekeeper to social services or benefits, that she really has the disorder. Her needs result in a choice that could then subsequently disqualify her for benefits (Coburn, 2006). If resistance is seen as a suffering human’s ability to reconcile herself with dominant medico-scientific narrative accounts of her body and comes at the expense of her own ability to define her treatment then this form of resistance is fundamentally disempowering. It may be a short-term adaptive strategy that confers limited temporary benefits but it is one that undermines her long-term coping skills and retards her growth as a person.

The control of treatment choice in exchange for disorder or sick-role status is the economic aspect of social control involved in the medicalization and psychiatrization processes. More overt forms of social control related to medicalization and psychiatrization have been documented since the 1960s. Foucault (1965) and Szasz (1974) both argue that the psychiatric profession has from its inception served a primary role in controlling socially unacceptable or deviant behaviour. Until the 1970s psychiatrists practiced mainly in custodial institutions and patients could be placed in care for indefinite periods of time and often for reasons that with hindsight seem questionable. Since the 1970s, psychiatric treatment has shifted to outpatient treatment in the community, with the subsequent increase in types of aberrant behaviour mentioned above, but within the last several years key thinkers have been pushing for a re-institutionalization of the behaviourally deviant (Martelli and Cottino, 2006). In Italy, the first country to de-institutionalize the mentally ill, a movement was beginning to emerge wherein ‘service users’ were having input into their treatments but unfortunately, due to the fact many psychologically disordered people are already disempowered socially, this movement seems to have been killed in its infancy by the more powerful interests representing the re-institutionalization movement (Martelli and Cottino, 2006). Perversely, the re-institutionalization movement is driven by appeals for the human right to ‘appropriate’ care and treatment of mental disorder.

Human Rights Based Approaches to Health

Ironically the human rights based approach to health advocacy may ultimately be the pathway for increased social control and surveillance of behaviours inimical to the goals of global economic development—including those of the global health industry. The ‘crisis of mental illness’ forecast by the WHO is said to be largely made up of ‘common mental disorders’, and in many areas of the world including modern industrialized nations such as Canada, depression and anxiety may be an appropriate response to the rapid deleterious changes of the neo-liberal policies that drive economic globalization (WHO, 2001; Coburn, 2006). Yet due to medico-scientific construction of depression and anxiety as potentially dangerous behaviours (Szasz, 2003), this normal human response to an increasingly hostile world is pathologized. Additionally, since human rights to health care and treatment services are negotiated through international treaties and WB and IMF loan conditions (Gordon, 2004), a vast potential for human-rights abuses exists within the implementation and re-structuring of health care programs across the globe.

The most powerful players in the game, the pharmaceutical and insurance companies, construction and engineering firms (hospital construction and maintenance) and the international professional organizations like the APA stand to gain in profit, prestige and power, while the ‘consumers’ of their diagnoses and products stand to lose their ability to resist. A diagnosis of even a common mental disorder carries with it the stigma of disbelief (i.e. a labour organizer with a history of mental illness is easily discredited) and a perceived dangerousness that is more often a danger to the ‘consumer’ than to her society (Szasz, 2003). The ‘human right to health’ was negotiated by various international institutions like the UN and WHO in good faith but has been hi-jacked by the needs of international capital. As Coburn (2006) argues “the wants of the wealthy trump the needs of the poor” (Coburn, 2006:67). Medico-scientific discourse conceptualizes and reinforces human experience in terms of the individual, which is why it goes hand in glove with the other more familiar consumer goods and services industries. Alternative understandings and conceptions of health and illness could lead to a critical analysis of the organization of society. This would be a financial negative from the standpoint of trans-national industries because it could lead to a change in the conception of the ‘good society’ to one based on quality of life (or moral experience) rather than on quantity of goods possessed (material satiety).

Conclusions

So, while serious steps need to be taken to critically examine our emerging global society and the power relationships contained with in its organization, this is not to say that medico-scientific classification and construction of disease is without benefit to humanity. It is rather a warning that medicalization is a process that is dangerous if undertaken without adequate sensitivity to the cultural needs of ‘consumers’ of health and illness and attention to the unequal distribution of benefits accrued. All humans should have an equal right to equal health but unfortunately under the free-market conditions of global capitalism do not share this right in practice. We should be wary of human-rights discourse around health if it does not require a fundamental overhaul of the social relations of global capitalism. Because, although medico-scientific advances in genetic research could unlock the cures for many of our most devastating human illnesses like cancer and HIV/AIDS, as we have seen in practice with regards to AZT in Africa, as long as ownership of the medico-scientific knowledge and technology is in private hands, only those with the money will be able to access the treatments.

Additionally, forcing disorder categories and pharmacotherapy onto populations that may be experiencing psychological turmoil due to the imperializing tendencies of global economic policies and practices is simply a form of scientific colonialism of the inner world of human beings. It also limits their ability to effectively criticize or resist economic and medico-scientific hegemony. While it may not be cost effective for HIV/AIDS treatments to become widely available in Africa or other centres of the AIDS epidemic, the extremely cheap and readily available first generation anti-psychotics and anti-depressants—affectionately nicknamed ‘chemical straitjackets’ (Whitaker, 2004)—make good economic sense from a productivity standpoint. These drugs make people more compliant and less resistant thus could guarantee an uninterrupted labour supply in countries experiencing the epicenters of the WHO’s predicted pandemic of common mental disorders.

Therefore the burden falls not only to social researchers, it falls to humanity as a whole to start a reevaluation process whereby the terms of human existence and wellbeing can be examined. The social relationships governing all aspects of living must be evaluated in terms of how they forward the wellbeing of all humans and increase the quality of life. This is a project not likely to pass easily into public consciousness and debate yet it is one that must be undertaken from a standpoint of the quality of lived experience and of species survival. The processes of global economics and medicalization degrade both the physical and mental environments to the point where conditions supporting the WHO’s predictions could soon hold globally. In order for humanity to create a groundswell powerful enough to force this situation to change, meaning must be constructed from this experience and value re-assigned to the experience of challenging life-processes. In short we must redefine the meaning of human lived experience.

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