Ways of Life in the Late Modernity

Palacký University, Olomouc Philosophical Faculty

Ways of Life in the Late Modernity Helena Kubátová et al.

Olomouc 2013

Reviewed by: prof. PhDr. Miloš Havelka, CSc. (Faculty of Humanities, Charles University in Prague) doc. PhDr. Bohuslav Šalanda, CSc. (Faculty of Humanities, Charles University in Prague)

The preparation and publication of this work was made possible by the financial assistance of the Ministry of Education, Youth and Sports in 2013 through the Institutional Development Plan, program V. Excelence, Philosophical Faculty, Palacký University in Olomouc: Support for Publications of Accademics at the Philosophical Faculty of Palacký University. This monograph has been published with the support of the Department of Sociology, Andragogy and Cultural Anthropology of the Philosophical Faculty, Palacký University, Olomouc.

First Edition © Helena Kubátová et al., 2013 © Palacký University, Olomouc, 2013 ISBN 978-80-244-3450-6

Contents

Introduction ............................................................................................................. 5 Ways of Life in the Late Modernity (Helena Kubátová) ..................................... 9 Part I Contexts of Ways of Life 1 Lifestyle in the Age of Liquid Modernity or the Consciousness of Necessity – Life in a Society of Keen Senses (Miloslav Petrusek) ......... 35 2 Religion as a Framework for Shaping Lifestyle in (Post) Modern Society (Dušan Lužný) .................................................................... 41 3 Late Modernity and the Transformations of Ways of Life: Rethinking Community (Jan Váně) .............................................................. 55 4 Pornography as Part of the Socio-cultural Changes in Lifestyle in Late Modernity (Jan Kalenda) .................................................................. 83 5 Lifestyle and Health (Kateřina Ivanová) ....................................................105 6 The Impact of Pharmaceutical Innovations on Human Identity and Lifestyle (Karel Čada)............................................................................125 Part II The Meaning of Life and Consumption 7 Way of Life in Current Mass Society versus the Spiritual Component of the Human Personality (Juraj Skačan) ...................................................143 8 The Way of Life from the Perspective of the Meaningfulness of Life as Perceived by College Students (Lucie Křeménková).................163 9 (De)tabooing of Death in the Context of the Current Consumer Way of Life (Erika Moravčíková) .................................................................193 10 Lifestyle, Consumption and Segmentation in Culture (Alois Surynek, Eva Jarošová, Ivan Nový) ...................................................211 11 Marketing Communication and Way of Life (František Zich) ................229 7

Ways of Life in the Late Modernity

Part III Dimensions of Ways of Life 12 Fatherhood as a Mode of Life and Style of Life (Martin Fafejta) ............247 13 Family in the Form of Unmarried Cohabitation as one of the Possible Life Styles of the Late Modernity (Miluše Vítečková) .....263 14 Changes in the Lifestyles of Silesian Families (Urszula Swadźba) ..........283 15 Holidays as an Element of Lifestyle (Ivan Chorvát)..................................299 16 Lifestyles in the Socially Excluded Areas of Moravian Cities and Towns (Daniel Topinka) ......................................321 Instead of a Conclusion .....................................................................................343 Bibliography .........................................................................................................345 Summary ..............................................................................................................377 Shrnutí ..................................................................................................................383 About the Authors ...............................................................................................391 Name and Subject Index .....................................................................................399

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6 The Impact of Pharmaceutical Innovations on Human Identity and Lifestyle

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The Impact of Pharmaceutical Innovations on Human Identity and Lifestyle

Introduction According to a number of authors (see, for example, Práznovcová, Strnad 2005; Iversen 2006; Goodman 2000) the pharmaceutical policies of developed European countries have had to respond to an escalation in the costs of medical drugs over the last decades. While in 1991, the average per capita spending on medical drugs in the Czech Republic was CZK 676, by 2003 it had risen to CZK 5118, which amounts to a more than seven-fold increase. For comparison, average per capita food expenditure in an average household rose approximately two-fold over the same period of time (ČSÚ 2005) and the living costs of employee households rose 3.6 times in 1990–2002 (ČSÚ 2005). The average expenditure on medical drugs in the EU was in fact 15 per cent higher than in the Czech Republic. In connection with this rise in costs, Jeremy Green has asked (2007) how and why has public health, previously associated with charity and science, become subject to such aggressive marketing. How is it possible that small fluctuations in blood pressure have become the object and product of mechanisms which bring together science and politics, economy and doorstep selling? The pharmaceutical markets thus represent one of the crucial, fastest-growing fields, an analysis of which can help us understand the social dynamics of late modern societies more generally. In analysing the root causes of these soaring costs, whether they are borne by states or individual households, we cannot rely solely on economic and public policy tools, but must also take into account the profound changes affecting medicine over the last fifty years. A number of these trends including medicalization, marketization of health or the importance of health promotion have been described in the previous chapter of this book written by Kateřina Ivanová. The social historian and theoretician of medicine John A. Pickstone (2000) describes the second half of the twentieth century as a period marked by a shift from “biographical medicine” to “techno-medicine.” In his view, traditional biographical medicine saw disease primarily as a malfunction of individual life and the treatment model centred on the doctor-patient unit. Over the course of the twentieth century, the emphasis gradually shifted

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towards “the power of ‘the medical gaze’ which has moved deeper and deeper into body structures – from surface anatomy, through X rays to intrabody physiology and now to genetics” (Webster 2002: 445). This new perspective has facilitated the definition and specification of diseases. The result has been an increase in the number of diagnoses, of medical drugs prescribed and developed, and of medical specialisations. Medical discourse has also managed to spread into a number of fields from which it had previously been absent: genetic testing and neuroimaging techniques have had an impact on the justice system, modern sexology and assisted reproduction have become far more common in the sphere of intimate life and questions of nutrition are increasingly framed in scientific terms. In contrast, technological progress carries on alongside the ever-louder criticism of the dehumanization of medical care. The creation of numerous patient self-help groups can be seen while there have been various patient empowerment initiatives (such as the antipsychiatry movement). In addition, alternative treatments based on a holistic approach to the body and disease are steadily gaining in popularity, while simultaneously broadening their offer (Scambler 1997: 35–46). In an effort to further conceptualize the sociological dimension of the development of medicine, the central concept has been the idea of medicalization, one of the key sociological themes of the second half of the twentieth century. This text intends to discuss the concept in relation to other notions associated with lifestyle changes proper to late modern societies, namely the concept of the reflexive self developed by Anthony Giddens (1991) and the concept of governmentality which expands on the ideas of Michel Foucault (see e.g. Dean 2010 or Rose 2006). In addition, I would also like to present the main revisions of the medicalization argument. These will consequently be used to further elucidate the mechanism of the practices of medicalization, by taking three specific drugs as examples: Prozac, Paxil and Viagra. The fact is that pharmaceuticals have played a crucial role in the medicalization process and have been among its most important drivers. As Adriana Petryna and Arthur Kleinman (2006) argue, “Worldwide, images of well-being and health are increasingly associated with access to pharmaceuticals.” In their view, the pharmaceutical drug has become one of the synonyms of modern medicine. One Czech physician summarises this approach as, “Disease is something that can be treated with an existing drug”.

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Medicalization in the Context of Late Modernity As with all other social institutions in late modernity, medicine itself has become an increasingly reflexive enterprise in terms of its knowledge base, its social organisation and the nature of everyday medical practice. Since the main contours of late modernity are broadly discussed in Helena Kubátova’s chapter in this book, the following part is focused on a discussion of the specific role of the process of medicalization in late modern identity forming. According to Peter Conrad (1992: 209), medicalization describes a process of defining previously non-medical problems in terms of medical pathology. The term first entered sociological literature in the 1970s. “Medicalization consists of defining a problem in medical terms, using medical language to describe a problem, adopting a medical framework to understand a problem, or using a medical intervention to ‘treat’ it” (Conrad 1992: 211). In this sense the concept falls under the heading of social constructivism, which has been used to study topics such as mental illness, alcoholism, homosexuality, addiction, hyperactivity and learning disorders, eating disorders, infertility or sexual dysfunction, amongst others. Kevin White (2009: 51–52) mentions three key characteristics of medicalization in present-day society. One, medicine as an institution defines the limits of normal behaviour and assigns responsibility for it. Two, it categorizes problems as individual and individually manageable (though obviously with expert help). Three, it classifies these problems as the product of nature, as the result of a genetic or biological dysfunction. As a process, medicalization is never complete and Conrad therefore talks about different degrees of medicalization. “In most cases medicalization is not complete; some instances of a condition may not be medicalized, competing definitions may exist, or remnants of previous definitions cloud the picture. Therefore rather than seeing medicalization as an either/or situation, it makes sense to view it in terms of degrees. Some conditions are almost fully medicalized (e.g. death, childbirth), others are partly medicalized (e.g. opiate addiction, menopause), and still others are minimally medicalized (e.g. sexual addiction, spouse abuse)” (Conrad 1992: 210). For example, the fact that insurance companies are unwilling to reimburse certain medical procedures or services does not mean that the condition to which these procedures pertain has not been medicalized, but only that it has been medicalized to a different degree, Conrad argues (2007:11). In practice, the degree of medicalization therefore determines to what extent the right to express views about a certain phenomenon, to take measures against it and to use it as a source of legitimization for exerting social control over others 127


becomes the prerogative of a single institution, modern western medicine. The process of medicalization always involves a negotiation between various groups which frequently express conflicting views. There are also a number of limits, such as competing definitions, medical care costs, medical categories or health insurance caps. Medicalization processes are also related to the opposing processes of demedicalization. A classic example is masturbation. Up until the nineteenth century it was a disease requiring medical intervention, while today it is seen as a common expression of human sexuality. In a different context, disability rights movements seek to demedicalize its members’ identities and to re frame disability as a different yet equally rich form of biographical experience. In other areas such as childbirth or obesity, we are currently witnessing a tension between medicalizing and demedicalizing discourses. In the case of childbirth, the discussion between the supporters of natural versus medically assisted birth revolves around the problems of rights and various forms of risks. In the case of obesity, the question is the very definition of the condition, which can be discursively framed in terms of an epidemic, as an identity, or a matter of social inequality. In all of these cases, the results will differ based on who is assigned responsibility and for what. Conrad mentions two main theoretical sources of inspiration for his concept of medicalization: the work of Talcott Parsons (1951), from whom these authors adopt several concepts while at the same time remaining critical of them, and the labelling theory. Parson was the first to conceptualize medicine as a form of social control. In his understanding, the ill person becomes freed from many of the expectations connected to his various social roles. Accepting the role of a patient normalises him and even justifies certain deviations from the norm and from the related expectations. On the other hand, he is now also subject to other norms, specific to his new role. Parson describes three main components of the patient’s role: (1) patients are freed from social obligations which they would normally have to meet; (2) they are not blamed for their condition; (3) ill people must be trying to get better; (4) being ill means being defined as an object of medical assistance which allows returning to normality. Parsons’ theory is a sound starting point for thinking about medicalization as it sets up a certain presumption of a consensus between the patient and the physician, which then serves as one of the foundations of this discourse. By accepting the role of a patient, the individual extricates himself from particular types of norms and commitments, while paying the price, metaphorically speaking, of subjecting himself to the control exercised by medical institutions.

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In addition to this, the labelling theory gives the medicalization approach its emphasis on process and the importance of a definition. A number of authors also refer to the work of the sociologist Ivan Illich, whose critique of modern medicine warns against the unrealistic ideas about health produced by medical professionals and pharmaceutical companies, ideas which further increase the demand for treatment. In his classic and highly controversial work Limits to Medicine – Medical Nemesis: The Expropriation of Health (Illich 1976), Illich calls this phenomenon iatrogenesis – harm caused by medicine – which he then characterises as clinical, social or cultural. According to Illich, virtually all aspects of human life are gradually brought into the sphere of physical or mental health: childbirth and child rearing, dealing with problems and hardships, criminal behaviour, sadness, ambition, all kinds of physical and mental abnormalities, but also death. They consequently become subject to medical control. Any suffering, grief or treatment that lies outside the role of a patient is defined as a normative deviation. “Powerful medical drugs easily destroy the historically rooted pattern that fits each culture to its poisons; they usually cause more damage than profit to health, and ultimately establish a new attitude in which the body is perceived as a machine run by mechanical and manipulating switches” (Illich 1976). Illich argues that medicine has become the institution defining who is ill, impotent or in need of any kind of repair. Illich’s theses have been further developed by a branch of sociology of medicine which Deborah Lupton calls the political economy of medicine. The Australian sociologist characterises its representatives as follows: “They see a symbiotic relationship therefore existing between capitalism and health care: capitalism produces health needs which are treated in such a way as to obscure their origins and demands the consumption of commodities to secure the healing process, which in turn supports the capitalist system of production” (Lupton 2003: 10). The political economy of medicine calls for a change in our dependency on medical technologies, for a decommodification of medicine, for the regulation of the interests of pharmaceutical companies, insurance companies and medical professionals, and for a redirection of financial and other resources to regulate the social and environmental causes of disease. On the one hand, modern states subject their citizens to social control in the form of numerous tests, vaccination requirements or by organising individuallytargeted campaigns, on the other hand, governments fail to regulate large companies so that they would create a more healthy environment, they do not take the necessary action against the production and marketing of unhealthy goods such as alcohol or tobacco, and do not act to increase accountability 129


in the testing and development of pharmaceutical drugs. “Medical care thus tends to be oriented toward the treatment of acute symptoms using drugs and medical technology rather than prevention or the maintenance of good health” (Lupton 2003: 10). Within this logic, a simple rule of three applies: the more symptoms we define as pathological and the fewer conditions as normal, the more drugs, tests and technological measures will be required to treat them. Medicalization as a Form of Governmentality Hasmanová Marhánková (2008) argues that medical discourse at present defines each pregnancy as potentially pathological and, referring to Lee and Jackson (200: 122, in Hasmanová Marhánková 2008), she adds that it can only be defined as normal after a successful childbirth, wherein a pregnancy “only receives the label of normality retrospectively.” However, the authors quoted also point out that the limits of what is considered a normal pregnancy or childbirth are constantly shifting. In her article, Hasmanová Marhánková discusses the experience of women who have refused prenatal screening. These women have defied the dominant medical discourse and, as a consequence, had a first-hand experience of medicalization practices. The author comments on one of the interviews, “While the obstetrician formally accepted her decision, Ms Ivana continued to feel his disagreement throughout the course of their subsequent regular meetings. The fact that she had refused testing therefore had a considerable effect on their relationship.” The patient attempted to free herself from the expectations and norms associated with the patient role (see Parsons 1951) and, seen from her doctor’s perspective, she did not seek to return to the norm. She therefore became, so to say, the odd one out, and was viewed as such, as irresponsible or a troublemaker. Ida Kaiserová addresses the question of social control in pregnancy even more eloquently: “From the moment of having conceived my first child, I became the object of normative interest of a number of institutions, such as the genetics laboratory, the maternity unit of the university hospital, the gynaecological surgery, the registry office, the department of social welfare, the paediatrician’s office, the child cardiology and endocrinology services, the nursery and the primary school, the child psychologist, but also the state railway company, the local bus company, the insurance company or the manufacturer of infant formula. All of them have also expressed a demand for my compliance. Becoming a parent has brought me into contact with a great many strangers, whose profession entitles them to tell me what to do, without my ever having felt the slightest interest in their views” (Kaiserová 2007).

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In this respect, medicalization as a type of manipulation is theoretically elaborated through the concept of governmentality. Governance is a more or less rationally calculated activity exercised by authorities and agencies, which use different techniques and forms of knowledge to pursue modalities of control that act upon other agents’ desires, aspirations, interests and beliefs (Dean 2010: 18). From this perspective, the way people manage themselves is seen as something that can be regulated, controlled, shaped and directed, depending on specific goals. As Peter Miller and Nikolas Rose demonstrate (1993: 93), this self-management is no longer influenced through coercion, but instead by using the power of truth, rational capacities and the enchanting promise of efficiency. Medicalization corresponds to Foucault’s concept of pastoral power, which refers to the development of technologies of power directed at the individual and his or her management. Pastoral power is exerted over a herd with the pastor-shepherd gathering and directing his herd and being responsible for its protection, which gives this form of power its seemingly benevolent character, the shepherd managing the herd for its own good. Subjecting oneself to the power of modern shepherds is never an intentional decision. “The care of the self involves largely, subliminal socialization rather than an active, conscious decision. It is about how people constrain themselves rather than being forcibly constrained by external agents, involving not generally explicit moral odes but a shared understanding of what is a ‘good person’ in a particular community” (Lupton 1995: 12). The key to its understanding then lies in examining how people restrain themselves in order to become good citizens. Nikolas Rose points out that modern pastoral power has long ago ceased to be unidirectional. As Rose argues and Kaiserová’s example shows, in real life pastoral power is often translated into a number of micro technologies. At times, the individual shepherds can even oppose and mutually undermine each other. They can appropriate our bodies, health or quality of life in a myriad of rhetorical ways, protect its different aspects and issue conflicting instructions as to what is best for us. Revisions of the Medicalization Approach As I have already mentioned, the medicalization thesis was formulated in the 1970s and reflects the state of medicine and its relations with the society of its time. Since then, we have seen a number of changes. The field of social control has become greatly diversified and is now a point of collision between numerous agencies and institutions, as Rose’s conception of pastoral power already holds. The American social anthropologist Adele Clarke and her colleagues have gone still further to suggest that the idea of medicalization should be replaced with 131


the concept of biomedicalization (Clarke et al. 2003). The bio- prefix highlights the importance of biotechnologies in the constitution of modern identities, while simultaneously making more explicit the reference to Foucault’s concept of biopower as power over life. The complex intertwining of spatially diversified and multidimensional processes characterised as medicalization is currently being reconstituted by the various forms and practices of the rapidly evolving field of technoscientific biomedicine. Clarke and other authors believe that the new concept should better reflect this situation, where the rise of new areas of medical genetics and transplantation medicine can be seen, as well as new medical technologies which further intensify medicalization in new, complex and mutually interlocking spheres of modern science and technology. While the original concept of medicalization only focused on the field of medicine, the new approach should pay more attention to medicine’s close connections with the biotechnological industrial complex. “Biomedicalization is reciprocally constituted and manifested through five major interactive processes: (1) the politico-economic constitution of the Biomedical TechnoService Complex, Inc.; (2) the focus on health itself and elaboration of risk and surveillance biomedicines; (3) the increasingly technoscientific nature of the practices and innovations of biomedicine; (4) transformations of biomedical knowledge production, information management, distribution, and consumption; and (5) transformations of bodies to include new properties and the proaction of new individual and collective technoscientific identities. These processes operate at multiple levels as they both engender biomedicalization and are also (re)produced and transformed through biomedicalization over time. Our argument, thus, is historical, not programmatic“ (Clarke et al., 2003: 163). The authors consider this the second significant social transformation of medicine. Paul Starr (1982) has described the first significant transformation as the post-war professionalization and specialisation of medicine and healthcare, which included the creation of associated professions, the application of new technological and pharmaceutical innovations and the appearance of specific new forms of medical care (hospitals and state-run or private clinics). In the United States, this period also saw the classification of medicine as a public good, which spurred increased investment in its development. As a result, medicine gradually entered a number of new areas. According to Clarke et al (2003), the original concept of medicalization was formulated precisely in response to this shift. It no longer reflects, however, the post-1985 changes connected with, among other factors, the continuing privatisation of research centres and commodification of scientific knowledge, where medicine becomes 132


significantly more ruled by managerial decisions and care is far less universal. More so than during the previous decades, medicine at present can adapt to both the patient’s body and their financial resources. Although healthcare is becoming increasingly more dependent on modern technologies, which also allow for both existing and potential patients to be supervised more easily and efficiently, medical care is simultaneously becoming more marketized. Together with Conrad (2007), I do not believe that on the general level this constitutes a radical reformulation of the medicalization argument. Instead one can speak of new drivers of medicalization (Conrad 2005) or of a marketoriented medicalization (Conrad and Leiter 2004). A much more radical form of critique can be seen coming from authors who question the authority medicine has held throughout recent decades. At present, western medicine has become only one of the variants on offer in the vast field of approaches to treatment. Patients can therefore choose classic western medicine, but also another of the proposed alternatives. Sarah Cant and Ursula Sharma (2000) describe this situation as “medical pluralism.” Different approaches in the same consulting room can even be encountered at present. British studies have shown that 20 per cent of all medical procedures carried out as alternative medicine, most often acupuncture or homoeopathic treatments, are administered by general practitioners (Thomas et al 2001). In addition to alternative treatments, our health is also increasingly influenced by other new professions: fitness trainers, dieticians, therapists and various personal coaches. It would therefore seem that medicine has lost its primacy of being the only institution to decide about our health. Although these new versions of medicine are just as eager to gain professional status (by creating schools and standards of training, founding professional associations, etc.), a number of studies have shown, however, that western medicine ultimately remains at the top of the pyramid (e.g. Kelner et al 2004 or Cant et al 2011). It is admittedly no longer the only institution in this field, yet it maintains its referential status and for a large share of patients still remains primary. Deborah Lupton (1995) makes the convincing argument that the discourse of the holistic approach to health and lifestyle in fact only helps foster the power of medical discourses over our lives. “In health promotion discourse, lifestyle is pathologized as a source of ill health” (Lupton 1995: 142). This discourse portrays health as a goal achievable through intentional action, one that requires self-discipline, determination, as well as the necessary time and energy. In the words of Anthony Giddens, “the self is seen as a reflexive project, for which the individual is responsible. We are not what we are, but what we make 133


of ourselves” (Giddens 1991: 75). The self is a kind of developmental trajectory leading from the past to the anticipated future, the British sociologist explains. In this perspective, our health is in our own hands, we are constantly making decisions about it and for these moments of decision we must be suitably informed and equipped. How many carbohydrates and proteins are there in each food, how should these be combined, how much water we should drink daily, what pulse should we maintain while running or what activities should we avoid on a full moon. Our lives are not ruled solely by the knowledge of western medicine, rather our thinking about health resembles a bricolage of scientific facts, unverified claims and traditional practices. This widening field does not undermine the possibilities of governmentality, however, in fact it only further strengthens them. Pharmaceuticals: Driving the Changes in Our Understanding of Human Identity As concerns pharmaceutical policy, the progressive medicalization of western societies can be seen in the milestones which medicine has reached in its quest to colonize new areas of human life. The following turning points are often mentioned in connection with the post-war history of medical drug use (see Potter 2002): the 1959 introduction of the first-generation oral contraceptives for women, developed by Gregory Pincus and Carl Djerassi in the 1950s; the first marketing of Ritalin, which helped define hyperactivity as a disease, in the 1960s; the 1986 launch of Prozac, a drug which raises the level of serotonin and thus induces a sense of security and well-being; the 1996 introduction, by GlaxoSmithKline, of Paxil as a treatment for social anxiety, and finally in 1998 the mass-marketing of Viagra, which is used to treat erectile dysfunction. What all these drugs have in common is that they allow the individual to manage something previously out of his or her control: conception, mood or sexual arousal. I am now going to examine the last three cases in more detail. As the historian of psychiatry Edward Shorter (1997: 320) argues, when Prozac entered the scene, depression lost its meaning as a symbol of distress. Shorter (Ibid) quotes one of the physicians working at the Beth Israel Medical Center in Manhattan, “Our phone rings off the hook every time someone does a story about Prozac.” He continues: “People want to try it. If you tell them they’re not depressed, they say, ‘Sure I am!’ ” In his book Listening to Prozac (1993), the American psychiatrist Peter D. Kramer discusses the initial reactions of patients who had tried the drug. Most of them described their

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state as feeling better than well. Similarly to cosmetic surgery, which can help people approximate a certain ideal of physical perfection, pharmaceuticals such as Prozac can remove minor imperfections of the human psyche. This is why Kramer calls them cosmetic psychophramacology. He argues that for a great many patients Prozac became the proof of biology’s victory over the psyche. “Prozac – a new antidepressant – was the main agent of change. There has always been the occasional patient who seem remarkably restored by one medicine or another, but with Prozac I had seen patient after patient become […] ‘better than well.’ Prozac seemed to give social confidence to the habitually timid, to make the sensitive brash, to lend the introvert the social skills of a salesman. Prozac was transformative for patients in the way an inspirational minister or high-pressure group therapy can be – it made them want to talk about their experience. And what my patients generally said was that they had learned something about themselves from Prozac. […] they believed Prozac revealed what was biologically determined and what merely (experience being ‘mere’ compared to cellular psychology) experiential” (Kramer 1993: xv). It was not just the patients whose self-perception changed, however, the same was true for their psychiatrists. “I had come to see inborn, biologically determined temperament where before I had seen slowly acquired history laden character”, Kramer (Ibid) describes his experience. Shorter writes that in 1993, six years after Prozac had begun to be massmarketed, about half of all psychiatric consultations in the United States concerned a mood disorder. In addition to patients suffering from clinical depression, Prozac was often used by people who would be considered clinically healthy but were looking to improve their quality of life. It became one of the first widely publicized drugs. In this sense one can speak, as for instance Conrad (Conrad 2005: 6) does, about a time before and after Prozac. “Marketing diseases, and then selling drugs to treat those diseases, is now common in the ‘post-Prozac’ era” (Conrad 2005: 6). In the post-Prozac era, the pharmaceutical industry has become more aggressive in promoting drugs, both among clinicians and the general public. In the 1990s, the U.S. pharmaceutical companies gradually began to exert more pressure on loosening the regulations on advertising drugs to the wider public. Their efforts bore fruit in 1997, when these rules became much less stringent (Lyles 2002). Following this legislative change, the marketing expenditure of the U.S. pharmaceutical industry grew six-fold between 1996 and 2000, reaching $ 2.5 b annually.

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Conrad gives another example of a pharmaceutical that contributed to the construction of a disease with a strong impact on lifestyle, Paxil. Prozac was launched by Eli Lilly in 1988 while Paxil appeared only ten years later, when the antidepressant market was already relatively saturated. Its manufacturer GlaxoSmithKline therefore decided to market the drug not as an antidepressant but as an anxiolytic. It specifically treated social anxiety disorder (SAD, an intense fear of social situations which may include a sense of shame) and generalized anxiety disorder (GAD, characterised as a chronic and excessive anxiety or worry lasting for more than six months). The decision was primarily motivated by the concern that facing the already fierce competition on the antidepressant market the drug might commercially fail. Rather than attempting to compete in an already saturated field, GlaxoSmithKline preferred to conquer a new one. SAD had already been included in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, which serves as a coding system for different types of mental diseases, in 1980, but before the late 1990s its diagnosis was fairly uncommon. “Since the FDA (Food and Drugs Administration) approved the use of Paxil for SAD (social anxiety disorder) in 1999 and for GAD (general anxiety disorder) in 2001, GlaxoSmithKline has spent millions of dollars on well-choreographed disease awareness campaigns to raise the public visibility of SAD and GAD. The pharmaceutical company’s savvy approach to publicizing SAD and GAD, which relied upon a mixture of ‘expert’ and patient voices, simultaneously gave the conditions diagnostic validity and created the perception that they could happen to anyone. Soon after the FDA approved the use of Paxil for SAD, Cohn and Wolfe (a public relations firm that was working for what was then SmithKline) began putting up posters at bus stops with the slogan, ‘Imagine Being Allergic to People’ ” (Conrad 2007: 18). The company portrayed the disease as both normal and abnormal, as a normal biographical condition, yet one that represents an abnormal bodily state. Although it is impossible to establish how many doses of Paxil have been prescribed for anxiety disorders and how many for depression, obsessivecompulsive disorder or post-traumatic stress disorder, which are among its other indications, the drug has overall been enormously successful, also thanks to its massive advertising campaign. Just before its patent expired in 2002, its sales stood at $ 2.1 b in the United States and $ 2.7 b globally. “The case of Paxil demonstrates how pharmaceutical companies are now marketing diseases, not just drugs,” Conrad concludes (2007: 19). The border between disease and normality was likewise blurred by Viagra, which caused a marked increase in the diagnoses of sexual dysfunctions. Prior 136


to Viagra, the treatment of sexual disorders was limited to only very serious conditions, such as in cases requiring prostate surgery. After its introduction it became possible to treat even lighter dysfunctions or indeed to use the drug simply to improve one’s sexual life. “Viagra’s début is a perfect opportunity to examine the construction of social norms, ideals and expectation, particularly because it renders visible many taken-for-granted social assumptions. I noticed this fixation on ‘normal’ when I started talking with people about Viagra,” writes the anthropologist Meika Loe in her book The Rise of Viagra (Loe 2004: 19). Pfizer, Viagra’s producer, presented the drug as a way for patients to return to normality. Its advertising suggested that what may indeed be common (it claimed that around half of all men over forty have suffered from or encountered erectile problems), is not, for that matter, normal. Loe shows that from the very beginning, Viagra walked the thin line between a medical pharmaceutical and a recreational drug. On the one hand it was presented as a serious treatment, on the other as an enrichment of sexual life. While Paxil cashed in on the loosening of advertising restrictions, Viagra made use of the new opportunities offered by online retailing. “In part due to its easy availability and association with sexuality, Viagra has become a recreational drug, most commonly used by young people, both gay and straight, in combination with Ecstasy – now known on the street as ‘Sextasy’ ” (Loe 2004: 176). “In an age of identity politics, both Viagra and Prozac have been claimed as tools for the construction of new and improved identities (masculine and feminine, respectively),” she continues (Loe 2004: 21). This is what distinguishes them from drugs treating conditions such as allergies or high blood pressure. The fact is that a simple cold or a number on the blood pressure monitor do not construct our identity, sexuality and depression do. “But the vision of the world is different for each pill: Viagra promises to restore sexual potency to the male populace, and Prozac promises to restore consistency, focus, and contentedness to, mostly, women’s lives; in sum, these pills are designed to produce potent men and happy women” (Loe 2004: 21). Conclusion The scope of medicalization is often illustrated by the sheer number of different psychiatric diagnoses. Compared with its 1952 version, the current edition of the aforementioned Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association contains three times as many diagnoses (Carrey 2008). It is therefore clearly apparent that present-day medicine continues to colonise areas which previously remained outside its rule, from relationship issues to problems in the workplace. It would therefore 137


seem that its strategy has proved greatly successful. However, as the cases of these specific drugs show, medicine itself is at the same time being colonized by other spheres of human activity. It reacts to both the current economic situation and specific expectations and norms. The three pharmaceuticals discussed above may serve as proof that biomedicine is by no means running out of steam and remains one of the principal drivers of changes in understanding human identity. In contrast, however, these developments cannot be understood as simply determined by technology: “Medical work is constructed as done on and through machines, but not by them” (Prout 1996: 203). The emphasis on the trajectories of specific human artefacts and their social grounding helps us avoid not only technological but also social determinism, which sees artefacts as simply the product of various discourses, ideologies, social structures and human intentions. By studying the trajectories of products such as medical drugs and the human interactions associated with them, light can be shed on the mutual interplay of social and material networks, their interpenetrations and interdependencies. What all of the analysed drugs have in common is that they allow the individual to gain control over something, these being attention, mood or sexual arousal. These were previously impossible to control and were instead perceived as natural. They also contribute to the construction of identities by allowing individuals to carry out targeted modifications and expand specific aspects of one’s self through acts of personal will. With their help, mental states such as sadness, anxiety in front of an audience or dread can be defined as avoidable and manageable. They indicate that what was previously seen as natural can now be controlled. These drugs also contribute to the redefinition of the categories of the biological and the social. Kramer mentions that Prozacusing patients would often state that they finally saw themselves clearly, once they had been freed of their supposedly biological depression, which had been preventing them from seeing their true self. The effects of Paxil or Viagra are framed in a similar way: as a return to normalcy, not as an added value. Within this identity-forming regime, these drugs are therefore not understood as a danger to authenticity but a means of achieving it. The author of a British study which interviewed parents of hyperactive children who had been prescribed Ritalin (Singh 2006) comes to a similar conclusion. A number of the parents agreed that it was precisely the medication that allowed them to perceive the true nature of their son or daughter. In this context a double understanding of normality can therefore be encountered: (1) the normality of the individual’s biography and (2) the normality of the body. The studied pharmaceuticals present the conditions they supposedly treat as normal from the perspective 138


of biography, you have nothing to be ashamed of, many people suffer from the same thing, etc. These are abnormal, however, from the perspective of the physical body, your body is not working properly, but it can be fixed. While holistic medicine advocates treating the mind and body together, these drugs highlight the very opposite claim: do not allow your body to prevent you from discovering your true self. The task of sociology is then not to judge whether these boundaries are just or not, but to study their reconfigurations in modern societies, with full respect for all the actors concerned. Last but not least, these pharmaceuticals have also become one of the elements fuelling the discourse of health as a matter of personal choice and responsibility. Medicine offers us various possibilities to be content, free of anxiety and enjoying a good quality of life. It is everyone’s responsibility to decide whether they want to benefit from these possibilities or not. These innovations therefore contribute to the discourse of the “imperative to health” (Lupton 1995), which relies, among other things, on the presumption that the individual is largely responsible for his or her health. He or she did not follow a proper diet, did not get enough exercise, drank too much or too little alcohol, took too few vitamins, did not provide his or her body with a sufficient amount of antioxidants or exactly the right amount of omega fatty acids. The reverse side of this structural pressure is consequently that less attention is paid to areas of health prevention such as work conditions, environmental burden or the weakening of social solidarity within public healthcare systems. The propensity of European governments for neo-liberal reforms based on the personification of healthcare therefore represents not only a solution derived from economic models, but also the result of how we think about our bodies and disease.

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About the Authors

About the Authors

Mgr. Karel Čada is pursuing a PhD degree in sociology at the Faculty of Social Sciences at Charles University in Prague. He focuses on the construction of pharmaceutical policy in the Czech Republic from both institutional and discourse perspectives. He has also participated in several research projects on social exclusion, inequalities in education and communication of science and has published articles in these fields. His work on the chapter was done under the auspices of the research project supported by the Czech Science Foundation “Social Dynamics Acceleration: Uncertainty, Hierarchical/Flat Governance Structures, and History Interiorization” (grant no. P404/11/2098). Contact: [email protected] Mgr. Martin Fafejta, Ph.D., is an Assistant Professor at the Department of Sociology and Adult Education, Palacký University Olomouc (Czech Republic). He is the author of “Úvod do sociologie pohlaví a sexuality” (An Introduction to the Sociology of Sex and Sexuality) and articles published mostly in sociological and philosophical periodicals. His research includes gender and minority issues, and discursive construction of identity. He is a member of the Working group on men and gender equality that was established by the Czech Government’s Council for Equal Opportunities for Women and Men. Contact: [email protected] Doc. Mgr. Ivan Chorvát, M.A., CSc., studied sociology at the Faculty of Arts at Charles University in Prague and at Central European University in Prague, completed his doctoral studies at The Institute for Sociology of the Slovak Academy of Sciences in Bratislava (1998), and achieved his Associate Professorship in Sociology with the Faculty of Philosophy at Comenius University in Bratislava (2010). He is currently working at the University of Matej Bel in Banská Bystricá (at its Science and Research Institute) and at the Faculty of Philosophy and Arts at Trnava University in Trnava (Department of Sociology), and as an adjunct instructor in the Faculty of Social Studies at Masaryk University in Brno (Department of Sociology). He is the author of the monographs “Voľný čas na Slovensku v sociologickej perspektíve” [“Leisure in Slovakia from a Sociological Perspective”] (2011 – as part of the publication Voľnočasové aktivity obyvateľov Slovenska (The Leisure Activities of the Slovak Population), “Cestovanie a turizmus v zrkadle času” (“Travel and 391

Ways of Life in the Late Modernity

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