What defines the value of a medicine? Based on an ethnography of the pharmaceutical industry, Q. Ravelli shows the omnipresence of manufacturers, of training in doctors’ offices, and the commercial logics that underlie medical uses.
It is as close as possible to the actors and their practices that the sociologist Quentin Ravelli sought the material constituting this critical analysis of the pharmaceutical industry and the drug market. Written in an immersive style, this work resulting from his thesis work offers the reader the opportunity to follow the commercial and scientific life of an antibiotic widely prescribed in France, the Pyostacinowned by the Sanofi laboratory.
To understand the functioning of this industrial actor, the author suggests observing him on a daily basis, in a work situation, in the exercise of his argumentative and organizational routines, far from the recent scandals which have affected the profession. The antibiotic analyzed thus has nothing in common with the career of the Mediator or Vioxxand the industrial issue analyzed is indeed routine: repositioning the Pyostacinmainly prescribed in dermatology, in the field of respiratory infections. From this perspective, the author shows us how the industrialist relies in particular on the growing phenomenon of antibiotic resistance to legitimize this “respiratory turning point” in the commercial career of this antibiotic.
A commercial biography
To the structuring question of this book: how to create use value, the author answers with a particularly detailed description of the modes of production of commercial arguments and the power relations at work in this sector saturated with conflict of interest. interests. Under the pen of Q. Ravelli, the sociological material becomes matter and the style deployed facilitates, whether the reader is an expert or a layman, immersion within this health industry. The reader thus has the opportunity to enter the factories, to wait in the waiting rooms in the company of a medical visitor, to observe the coded exchanges between her and her client, to discover the organization of the conferences medical and the staging of scientific marketing, to understand the functioning of these industrial players through an analysis of the architecture of the head office and the location of the different services within it.
He discovered how competing manufacturers joined forces to monitor the prescriptions of each doctor: “I understood that I was being tricked, that they knew exactly what I was prescribing (…). I was naive, I didn’t know. (One day), a health visitor said to me: “You don’t prescribe much!”, I asked myself: “How can she know that?” » (p. 78). Another revealing example of the richness of this book, the description of the organization by the Sanofi laboratory of mock competitions for medical internships, in close collaboration with university deans, which allows us to appreciate, from an original angle , the extent and diversity of the influence strategies at work in this sector. A device that “makes it possible to identify future influential doctors even before they reveal themselves to themselves” (p. 126).
The author offers a “social biography of the commodity” constructed at the intersection of the cultural anthropology of James Frazer and Bronislaw Malinowski, the political economy of Adam Smith and Karl Marx, and the sociology of work of Michael Burawoy. and the sociology of science of Bruno Latour. The stated ambition is to capture major socio-political upheavals through an “extended case study”: the “mutations of an economic sector, revealing developments in contemporary capitalism” (p. 17). The justification of this theoretical framing and the discussion of the authors to which it gives rise inform us about the political dimension of this work.
The ambition is indeed that of a critique of contemporary capitalism through the analysis of one of its most powerful and visible representatives in the public space: the pharmaceutical industry. The possibility given by Sanofi to a doctoral student in sociology to work within it for several months (under the status of intern), in different departments (marketing, production), to carry out dozens of interviews, to use internal documents, shows that this sector, deemed opaque and secret, can be observed from the inside, under certain conditions. We regret on this last point that the author does not provide more information, in the manner of the anthropologists to whom he refers, on the conditions of his acceptance within this company and especially on the evolution of these relationships after the publication of the thesis and possible oral feedback to the actors observed.
The presentation of this reflective work could have allowed the author to better clarify his relationship to the object, his methods of engagement in research as well as the methodological limits of this participant observation system. The interest of this empirical work lies, beyond its high analytical quality, in that the author was able to observe a very particular phase in the history of this laboratory and more generally of the pharmaceutical industry. It thus shows us how two congruent phenomena, the sudden slowdown in innovation in this sector and the multiplication of health crises and lawsuits, are forcing manufacturers to reorganize production, to redeploy their research, marketing and influence strategies. . From this perspective, a question would have merited debate: how does this publication contribute to the strategy of transparency in which this industrialist, and the others, are currently engaged?
An industry without safeguards
As we have already suggested, the style of this work is original. The ambition is obviously to also address an audience of non-specialists. The division of the book into three large parts entitled respectively, Sell, Produce, Seekgreatly facilitates the reading and understanding of a sometimes dense text. This popularization work in a very technical and still very little-known field is not done to the detriment of the logic of proof. The work is in fact extremely rigorous and provides the scientific community with a commercial biography and by extension, an industrial fresco likely to be of interest to sociologists of work as well as those of health.
However, it seems to us that this division, undoubtedly guided by editorial requirements, by forcing the author to treat the question of the marketing of drugs separately from that of research, does not facilitate the explanation of the notion of Scientific marketing (Gaudillière & Thoms, 2015). The author is thus the victim of what one could call expository relativism when he favors in his presentation the commercial dimension of the biography of this drug at the expense of a more systematic description of the scientific anchoring of these commercial speeches. The following comparison between the wine and drug markets is a good example: “Despite a more scientific singularization regime for the wine and spirits market, the drug market shares with it the same uncertainty of quality” (p. 62). Reading the first part, Sellthus leaves the reader with the impression of extreme malleability of the data resulting from clinical research, which it would suffice to interpret, as one interprets a classic text, to identify a new indication and therefore a new market. This game around words and statistics participates in the evolution of the therapeutic indications of the drug studied, but it would have been desirable to explain more clearly the conditions of possibility of these interpretations by analyzing more precisely the upstream: clinical drug research and its financing.
The third part, entitled Search – beyond conflicts of interestpartly corrects this exposure effect by notably offering a very enlightening ethnography of the organization of medical conferences and the game of masks played by clinicians and laboratories to make the omnipresence of the latter in these scientific events acceptable. It would undoubtedly have been desirable to go further in this part in order to better explain the conditions under which clinical data on drugs are produced, by better highlighting the effects of massive funding of clinical drug research by the pharmaceutical industry. This specific economy of clinical research effectively subordinates scientific questioning to the commercial logic of laboratories and provides manufacturers with almost total control of the scientific agenda on their molecules (Dalgalarrondo, 2004). It is also here that, to use the author’s words, “the use value of new antibiotics” is “subject to the economic requirements of their exchange value” (p. 19). Thus, even if it is perfectly legitimate and interesting to emphasize the analysis of the “commercial gesture” as a creative source of value, a more in-depth presentation of the functioning of clinical research, of the conditions for developing protocols for trials (choice of comparator, duration, patient profile, etc.), the dynamics of matching between hospital and industrial clinicians, the content of the exchanges between these two types of actors would have made it possible to better understand the strategy commercial implementation by the Sanofi laboratory. We can also regret that the history of the evolution of recommendations from learned societies or public agencies (HAS, ANSM) in favor of this “respiratory turning point” of Pyostacin not be more precise. Analyzing the professional background of the doctors working in these places of expertise and their links with the Sanofi laboratory would undoubtedly have provided food for thought on conflicts of interest.
The pharmaceutical industry has received increased attention from the social sciences in recent years. Q. Ravelli’s work is an important contribution to the understanding of the drug marketing system and reveals, to its extent, the major changes taking place within this sector. By highlighting the risks inherent in this quest for market share freed from any public health imperative, Q. Ravelli rightly reminds readers that medicines are also potentially “monstrous” goods sold by manufacturers.
The ethnographic quality of this work allows us to get as close as possible to the capacity of influence of pharmaceutical laboratories, often denounced, but rarely the subject of direct observation. The exposition of the diversity of strategies implemented is nourished by the author’s keen eye for revealing details. The conclusions are firm and critical: the risks of capture of regulatory bodies, scientific communities as well as the political, scientific and cultural domination exercised by this powerful actor are clearly stated. The observation is all the more interesting as it is made in a major area for public health: antibiotic therapy. The issue of resistant bacteria now benefits from a tight sociological perspective, in which the commercial logic of the pharmaceutical industry and its harmful effects on public health are perfectly documented.