Harms to Health from the Pursuit of Profits
DEADLY MONOPOLIES: The Shocking Corporate Takeover of Life Itself—and the Consequences for Your Health and Our Medical Future. Harriet A. Washington. xiv + 433 pp. Doubleday, 2011. $28.95.
In the midst of current economic contraction and disarray, it has become a struggle to get the general public to contemplate just how deep the corruption of the current system extends. In an era when political leaders promise deliverance from decline through America’s purported preeminence in scientific research, the news that science is in deep trouble in the United States has been as unwelcome as a diagnosis of leukemia following the loss of health insurance. Indeed, the consequences of the neoliberal commercialization of both science and health care since 1980 have eroded the previous superiority of best-practice standards for both of those pursuits in the United States, and their degradations are now intimately intertwined.
In Deadly Monopolies, Harriet A. Washington seeks to describe and diagnose the malady as it has afflicted health care and the pharmaceutical industry in the United States. It appears she may have hoped to capitalize upon the recent popularity of books such as Rebecca Skloot’s The Immortal Life of Henrietta Lacks. To that end, Washington passes up the chance to systematically survey the immense existing literature on these topics and to present hard evidence concerning the parlous state of U.S. health care compared with that of other nations. Instead, she elects to offer a sequence of vivid narrative vignettes describing individual travails and travesties, interspersed with broad, prosaic generalizations such as these: Drug prices are exorbitant. Drugs of dubious benefit seem to proliferate. Commercialized researchers appropriate tissues and body parts without real consent or payment. Subjects in drug trials are treated with callous indifference, especially in the third world. The imperative of profits preempts treatment of all manner of people. Researchers tend to ignore the diseases and conditions that afflict the vast mass of the needy. Articles in medical journals have become untrustworthy. Patents are used to expropriate the most extraordinary bits and pieces of biology, which the average person would be shocked to consider inventions. None of this is especially new or noteworthy to those who have followed the literatures on science and health care, so the value added would presumably have to come from the book’s capturing the attention and imagination of people who have had neither the time nor inclination to pay close attention to the many and varied perversions of pharmaceuticals research. I regret to report that the odds of Deadly Monopolies recapitulating Skloot’s success are not very high.
Henrietta Lacks succeeds because it tells a true-life story that is sustained by the sheer incongruity of the immortality of the HeLa cells taken from Lacks’s tumor contrasted with the ironies of the tenuous lives of Lacks and her offspring and the increasing commercialization of the HeLa cell line. There is no equivalent narrative arc in Deadly Monopolies, in part because Washington never sustains any particular incident long enough to turn it into a morality tale. Instead, the book displays a distressing deficiency of logical organization, such that arguments often peter out long before they have been marshaled into a bill of indictment. All manner of loosely connected issues get drive-by critiques, including the meaning of monopoly, the Bayh-Dole Act, Joseph A. DiMasi’s estimates of the costs of drug development, “me-too drugs,” gene patents, U.S. Food and Drug Administration incentives, ghost-written journal articles and biocolonialism. Unfortunately, whenever Washington suspects that she may have missed the target the first time around, she circles back for a second pass at the same topic in a subsequent chapter, as when she canvasses the diverse legal definitions of consent after devoting an earlier chapter to informed consent. Her attempts to relate arcane technical issues to the lives of ordinary people are perfunctory and rushed, often relying on a high “yuck factor” rather than deliberate explanation. She often inserts personal reminiscence at awkward junctures rather than building up accounts of research gone awry from first principles. Perhaps more telling, she seems unsure of just why commercialization of research and health care should have led to such dire straits in the first place, opting at various points to blame the root corruption on “monopoly,” perhaps because she is uncomfortable with delving into economic arguments over how best to structure research. This ends up being unavailing, because modern configurations of biotech firms, Big Pharma and contract research organizations (which carry out most drug trials) do not strictly qualify as monopolies. If Washington instead intended the indictment to refer to patents, her complaints misfire, since she is unwilling to engage with legal and economic aspects of intellectual property in any detail.
There already exist a number of exemplary popularizations of the issues at hand, and it is a shame that Washington almost never engages with them. Marcia Angell, Jerry Avorn and Paul Nightingale have written forcefully about the failures of drug research, Adam Jaffe and Josh Lerner about the broken patent system, Jill A. Fisher about the mistreatment of subjects in drug trials, and Sergio Sismondo about the plague of ghost-written articles in medical journals. Indeed, even National Public Radio has broadcast a trenchant indictment of the current patent system: “When Patents Attack” (This American Life, July 22, 2011) is a small masterpiece of popularization. Deadly Monopolies does not inform the general reader of the best work on the topic.
Perhaps more distressing is the fact that the book is already out of date in some important respects. For instance, in chapter 5 Washington praises at length the invalidation of the Myriad Genetics patent on breast cancer genes in 2010 by the Federal District Court in Manhattan. Although she does note that the decision was reversed on appeal at the Federal circuit level in July 2011, she brushes this aside by suggesting that there will be further appeal. In doing so, she fails to consider how the purview of intellectual property has been extended in the past; an important insight of Jaffe and Lerner is that the Federal circuit court plays a critical role in fortifying patents in novel areas. Elsewhere, Washington extols the activities of a patient interest group that is attempting to promote research by claiming intellectual property, but she says nothing about recent research into the ways patient groups have been astroturfed by Big Pharma. Her discussion of patents is not very precise, and it has been further compromised by passage of the Leahy-Smith America Invents Act in September 2011. The general consensus is that the act, far from being any sort of reform, will have no substantial impact on the decline of patent quality that has occurred over the past two decades in the United States. Furthermore, the act will fortify the existing stranglehold of large corporations on intellectual property; the only increase in employment it may jump-start is that of more lawyers in an already bloated system of wasteful litigation. It does nothing to reward actual invention. Reprising journalists’ talking points from 2010, Washington highlights the role of the pharmaceutical industry in helping to pass Obama’s health care reform. She admits that the industry received a pass on price controls, but she makes no mention of more recent arguments that the early intervention of these firms was a major factor frustrating the introduction of a single-payer system, the only structure that has demonstrated a capacity to contain out-of-control health care costs.
It is one thing to set out to provoke moral outrage over a cruel and unjust system, as Washington seeks to do; it is another thing altogether to structure sufficient evidence and argument to allow readers to begin to understand what needs to be changed in order to reverse the decrepitude of a once-great research base and to make biomedical research once more support the general health of the nation and the world. For instance, her prescription to simply repeal the Bayh-Dole Act reveals an extremely narrow understanding of the myriad ways in which both academic and corporate scientific research have been dramatically and irreversibly altered by the imperatives of commercialization of knowledge and the withdrawal of the state from responsibility for maintaining public universities and a vibrant national science base. The offshore outsourcing of manufacturing has done far more damage to the quality of scientific research than a few patents appropriated by some universities in the vain hope of tapping into major sources of revenue. Materials-transfer agreements corrupt science to a greater degree than patents do. And the systematic distortion of the reporting of research through ghostwriting, the hiding of data from clinical trials, and think-tank agnotology have undermined science far beyond the effects of some advertising in medical journals and Pharma-paid junkets for doctors. The neoliberal default presumption of an infallible marketplace of ideas is much more influential than a few nonprofit open-science consortia. Making readers see what needs to be changed is a tall order—it requires pulling back and taking in the bigger picture, and helping them understand political economy as well as the science involved. Bite-size stories of harried citizens struggling to take their medicine don’t suffice.
Philip E. Mirowski is Carl Koch Professor of Economics and the History and Philosophy of Science, University of Notre Dame. He is the author of several books, including Science-Mart: Privatizing American Science (Harvard University Press, 2011) and The Effortless Economy of Science? (Duke University Press, 2004).