Conference Report: "Is this the End?", Zurich, 4-6 October 2012.
Is this the End? The Eclipse of the Therapeutic Revolution
4 - 6 October 2012, University of Zurich, Switzerland
Conveners: Christian Bonah, Flurin Condrau, Christoph Gradmann, Jakob
Tanner, Carsten Timmermann, European Science Foundation Research Network
Programme DRUGS
Report by: Anna Kathryn Schoefert, Cambridge. Email: <aks63@cam.ac.uk>.
and Pierre-Oliver Methot, Geneva. Email:
<pierre-olivier.methot@unige.ch>.
Following conferences and workshops in Strasbourg, Berlin, Paris the
European research network on pharmaceuticals in the twentieth century
[1] invited historians and anthropologists to reflect on the
"therapeutic revolution", its postulated end(s) and its possible
future(s). Charles Rosenberg's well-known 1977 essay first located a
therapeutic revolution in the late nineteenth century, linking it to
changes in ideas, economies, and professions which fostered and helped
sustain new forms of healing practices. [2] Most historical accounts now
stretch the therapeutic revolution from Rosenberg's late nineteenth
century to the 1960s.The conference, hosted by the Institute and Museum
of the History of Medicine at the University of Zurich, challenged the
occasionally exaggerated linearity of these accounts: Over three days
participants and discussants offered wide-ranging views of therapeutic
worlds in the second half of the twentieth century. Touching upon lived
experiences of patients and other actors and agents, entwined notions of
regulation and individual responsibility in pharmaceutical use,
frictions between standard therapies and local sites of practice, and
the manifold specificity of nations, cultures, and markets, the
contributors discredited the description of a singular therapeutic
revolution or a singular moment of its eclipse.
The opening keynote by SCOTT PODOLSKY (Harvard) analysed the 1960s and
1970s, often postulated as the decades of the therapeutic revolution's
decline. Podolsky examined discussions in the US on delimiting
physicians' prescription activities. These debates arose from anxieties
of antibiotic resistance and an overmedicated society. Spanning the 1962
Kefauver-Harris Act, they invoked physicians influenced by patient
demands and pharmaceutical marketing, and recommended that government
regulations or professional guidelines be put in place to curtail
"irrational" prescription habits. Though regulators removed some
medications from the market, physicians ultimately resisted external
standardisation and maintained their prominent role in directing patient
care.
Pharmaceutical markets post-1960 were the focus of the first session.
NILS KESSEL (Strasbourg) and CHRISTIAN BONAH (Strasbourg) presented
their preliminary analyses of pharmaceutical sales data amassed by the
International Market Services (IMS) from the late 1950s. Delineating the
source's limitations, they highlighted opportunities to question,
contextualise, or bolster arguments about increased pharmaceutical usage
and market developments with this rich quantitative data. They showcased
the difference between the cultural - and historiographic - visibility
of emergent drug classes and the continued material existence,
popularity, and economic significance of over-the-counter tonics and
medications. In her paper, JULIA YONGUE (Hosei, Tokyo) brought the
discussion to the present. While elucidating national differences, she
traced how vaccines have recently become a high-growth industry and
market subject to public-private partnerships, global research and
funding initiatives, and large-scale mergers. Yongue stressed the
multiplicities of what might constitute or be marketed as a therapeutic
revolution - from combination vaccines and vaccinations against cancer
to heat-stable vaccines or single-dose childhood vaccinations.
Continuing the conversation on pharmaceutical development JEREMY GREENE
(Johns Hopkins) held the public lecture, speaking on an ambiguous
element of the therapeutic revolution, generic drugs. He accentuated
generic drugs as branded, marketed, and increasingly linked to global
strategies of multinational firms and organisations just as patented
drugs. He highlighted the bifurcated rhetoric of generic drugs: hailed
as opportunity for access and condemned as cause for the revolution's
demise and impediment for its recurrence. Pointing to the historic role
of minor modifications in pharmaceutical design Greene cautioned against
a binary imitation/innovation and against simplistic models of a
productivity crisis in the pharmaceutical industry.
Starting off the second day, and beginning a session concentrating on
chronic drug use, ALEXANDRE MARCHANT (Paris Ouest) compared French and
Dutch configurations that allowed for, or prevented, institutionalising
drug substitution models in reaction to the "new plague", the 1960s
"drug epidemic". Whereas the Netherlands quickly embraced methadone
therapy systems that engaged multiple stakeholders and adapted to local
conditions, France initially permitted only a few official trials,
perceiving drug abuse as a local concern in Paris and Marseille, and
understanding opiate addiction as an iatrogenic problem best treated
with psychosocial approaches. AARON GOODFELLOW (Johns Hopkins) followed,
detailing narratives of chemical dependencies and subject formation in
pharmaceutical systems as observed during fieldwork in Baltimore. He
drew attention to recurrent motives of being slave to a drug or of being
the powerless inhabitant of a machine body driven by metabolic
processes. Whereas Goodfellow described alienated selves, MAGALY TORNAY
(Zurich) discussed life-style drugs and the use of psychoactive
substance as form of "empowerment". She identified self-informed
healthcare consumers who produced private knowledge about
pharmaceuticals and post-therapeutic selves. She hinted at underlying
ambivalences in adopting existing diagnostic categories and marketed
products while also viewing pharmaceutical and medical industries with
suspicion. Based on fieldwork at German transplant centres KATRIN
AMELUNG (Göttingen) addressed a different ambivalence in "drugs for
life". She described the post-therapeutic life after organ
transplantation, an after-life often defined in militaristic terms of a
body at war with its immune system requiring continuous compliance work
and recalibration to maintain immunosuppression. STEPHEN PEMBERTON
(NJIT) then spiralled out to larger narratives of drugs for life, here
in haemophilia. He juxtaposes standard accounts of technological
progress key to many histories of haemophilia with the "ironic"
consequences of "successful" medical management also prominent in these
histories. He closed emphasising the multiple therapeutic modalities and
shifts in treating haemophilia, each potentially revolutionary for
relatives and patients.
In her keynote address, JULIE LIVINGSTON (Rutgers) problematised the
vision of drugs as universal tools, a vision central to many models of
the "therapeutic revolution". Drawing from fieldwork in Botswana's sole
cancer ward, Livingston poignantly showed efficacy rendered
significantly more complicated when side effects, resistance,
co-morbidity, and site specificity are considered. In Botswana, and
elsewhere, the successful introduction of antiretrovirals has led to a
surge of viral-associated cancers and exposed existing rates of cancer.
For patients, relatives, and carers this new site of biomedicine with
its complicated epidemiological and biological profile and its location
on the periphery of oncology hovers between chemotherapy as emblem of
hope and medical progress and the lived experience of crippling side
effects and harsh choices of access.
The following session's papers on the political economy of drugs, all
based on fieldwork in Africa, foregrounded other aspects of
pharmaceutical-based therapies. FANNY CHABROL (EHESS Paris) focused more
closely on the micropolitics of antiretroviral treatment in Botswana.
She examined the formation of a pharmaceutical citizenship that
explicitly links citizenship and access to drug treatment. Such
pharmaceutical citizenship renders compliance with biomedical treatment
regimens into a citizen's obligation towards the caring state. NADINE
BECKMANN (Roehampton) further elucidated assumptions of
responsibilisation bound up in many HIV treatment programs. She
highlighted that these programs often privilege physical over social
lives, presupposing biomedical selves, logics of choice, and narratives
of empowerment, partnership and knowledgeable and responsible
consumer-ship often at odds with the highly complex social settings.
KRISTIN PETERSON (UC Irvine) turned to the speculative drug market in
Nigeria after the 1970s, the purported end of the therapeutic
revolution. Tracing economic from the 1970s expansion and the 1980s bust
following foreign divestment she described the structures of Nigeria's
current large informal pharmaceutical market.
Opening the third day of the conference, VIVIANE QUIRKE's keynote
(Oxford Brookes) explored how the multinational pharmaceutical industry
and its researchers experienced the "end of the therapeutic revolution"
and the shift to biotechnology, describing both formal and emotional
reactions. While firms tended to adopt cautious approaches,
commercialising the new learning and adapting new technologies to
existing models of drug design, feelings of nostalgia and
disillusionment dominated among researchers. Quirke highlighted the
presence of continuities and steady transitions as well as of major
shifts.
The subsequent, penultimate session investigated questions of risk and
responsibility. In their joint paper NICOLAS HENCKES (CERMES3, Paris)
and STEEVES DEMAZEUX (CERMES3, Paris) questioned whether the powerful
blanket narrative of medicalisation accounted for the emergent diagnosis
of pre-psychosis. Despite unstable diagnostic criteria, imprecise
treatment models, and uncertain transition rates from pre-psychosis to
psychosis, the risk of psychosis has been increasingly construed as
illness category, mangling risk and disease and utilising the desire for
treatment voiced by some individuals classed as high-risk as argument
for diagnostic categories. Problems of screening and diagnosis also
featured in the paper by SOPHIE CHAUVEAU (Belfort-Montbéliard). Chauveau
reiterated the differences between screening, treating, and curing in
mid-twentieth-century clinical practice. She noted tensions between
individual and collective, the range of clinical techniques appropriated
for screening, oft-occurring lags between calls for screening and
availability of suitable screening tools, and assumptions about
behaviour post-screening.
The final session turned to natural drugs and markets. Discussing
developments in antibiotic use in German meat production since the
1950s, CLAAS KIRCHHELLE (Oxford) elucidated the growing public unease
about such "chemical" additions. He pointed to difficulties of
regulating and measuring antibiotic usage and analysed why agricultural
producers were unable to break the association of sub-therapeutic doses
of antibiotics with poison, food adulteration, and dangerous chemicals.
KLAUS ANGERER (Humboldt) shifted the focus from animal to plant worlds.
He investigated current practices of natural drug discovery that fit
uneasily into standard approaches to drug screening and development and
that raise worries about origin, bio-piracy and responsibility invisible
in earlier drug development models. Rounding out the session, DAVID
TEIRA (Madrid) probed a key concept of the public acceptance of clinical
trials, their cloak of impartiality. He argued that if the public sought
to uphold such trials as source of innovation free from industry
influence then clinical trials should be supported by public funds.
Engaging the question posed provocatively by the conference organisers,
"Is this the End?", participants and presenters proposed a myriad of new
beginnings, continuities, and moments of eclipse in the present and
recent past of pharmaceutically based therapies. Investigating the
employment and use of the trope of 'therapeutic revolution' and its
postulated eclipse was as significant in the discussion as the
shattering of the monolithic figure itself. An attendant, more in-depth
discussion of this label and its features may be useful to address
persistent narratives in twentieth-century biomedical history and
historiography.
Held at the University of Zurich, the conference was supported by the
European Science Foundation, the Swiss National Fund, the University of
Zurich, and the Centre for the History of Knowledge at the University of
Zurich.
Conference Program: Is this the End? The Eclipse of the Therapeutic
Revolution
Welcome
Flurin Condrau (Zurich) and Jakob Tanner (Zurich)
Keynote
Scott Podolsky (Harvard): "Multi-Resistance": Antibiotic Resistance and
Delimitations of Physician Prescribing Activity.
Session: Beyond the Therapeutic Revolution
Janina Kehr (Zurich): Chair
Nils Kessel (Strasbourg) and Christian Bonah (Strasbourg): What was it
all about? Reframing Drug Innovation, Sales and Consumption Approaches
1960-1980.
Julia S. Yongue (Hosei, Tokyo): A New Golden Age for the Global Vaccine
Industry? The Impact of Public Health Policies on the Eclipse or the
Dawn of the Therapeutic Revolution
Public Lecture
Flurin Condrau (Zurich): Chair
Jeremy Greene (Johns Hopkins): The Generic Future: Imitation,
Innovation, and the End of the Therapeutic Revolution
Session: Drugs for Life
Sandra Eder (Zurich): Chair
Alexandre Marchant (Paris Ouest): The Physician, Methadone and the Drug
Epidemic: A Comparison Between France and the Netherlands, 1970s - 1980s
Aaron Goodfellow (Johns Hopkins): On Being Worked Towards Death:
Chemical Dependency, Slave Narratives, and Biological Citizenship
Magaly Tornay (Zurich): Lifestyle Drugs and Post-Therapeutic Selves
Katrin Ameland (Göttingen): Immunosuppressant Drugs and "Transplanted
Health"
Keynote
Carsten Timmermann (Manchester): Chair
Julie Livingston (Rutgers): Chemotherapy in the Shadow of
Antiretrovirals: The Ambiguities of Hope as seen in an African Cancer
Ward
Session: Political Economy of Drugs
Niklaus Ingold (Zurich): Chair
Fanny Chabrol (EHESS Paris): Antiretrovirals in Botswana: Attractive
Global Pharmaceuticals and National Sovereignity
Nadine Beckmann (Roehampton): Saving Lives: Antiretrovirals,
Responsibilisation and the Logic of Choice
Kristin Peterson (UC Irvine): Speculative Drug Markets: Monopolies and
Derivative Life in Nigeria
Keynote
George Weisz (McGill): Chair
Viviane Quirke (Oxford Brookes): When Drug Standards Change, and
Standard Drugs Come to an End: Pharmaceutical Companies and the Advent
of Biotechnology
Session: Risk and Responsibility
Jean-Paul Gaudillière (CERMES3, Paris): Chair
Nicholas Henckes (CERMES3, Paris) and Steeves Demazeux (CERMES3,
Paris): Psychosis Risk Syndrome and the Limits of Psychopharmaceutical
Invention
Sophie Chaveau (Belfort-Montbéliard): Screening: A New Instrument of
Public Health Policies?
Session: Biomarkets
Christoph Gradmann (Oslo): Chair
Claas Kirchhelle (Oxford): Contagious Chemistry: The Eclipse of
Subtherapeutic Antibiotics in West German Agriculture (1951-1990)
Klaus Angerer (Humboldt): Bioprospecting since the 1990s - the
Beginning or the End of Natural Product Research in Drug Discover?
David Teira (Madrid): Patents, Pharmaceutical Monopolies and the
Impartiality of Clinical Trials
Closing Remarks
Flurin Condrau (Zurich)
[1] (DRUGS): Standard Drugs and Drug Standards: A Comparative
Historical Study of Pharmaceuticals in the Twentieth Century, a European
Science Foundation Research Networking Programme.
<http://drughistory.eu/>.
[2] Charles Rosenberg (1977). "The Therapeutic Revolution: Medicine,
Meaning, and Social Change in Nineteenth Century America", in:
Perspectives in Biology and Medicine 20(4): 485-506.