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The Pharmaceutical Person

Article  in  BioSocieties · September 2006

DOI: 10.1017/S1745855206003012

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BioSocieties (2006), 1, 273–287 ª London School of Economics and Political Science
doi:10.1017/S1745855206003012

The Pharmaceutical Person

Emily Martin
Department of Anthropology, New York University, New York, USA
E-mail: em81@nyu.edu

Abstract
This article is based on an illustrated talk I presented at the British Museum as part of the lecture
series ‘Making things better’. The central exhibit in the newly opened Wellcome wing of the
museum was ‘Cradle to grave’, a 40-foot table displaying in black net fabric the 14,000 pills taken
by a British man and woman over their lifetimes. I trace the historical development of personhood
in relation to psychotropic drugs over the last few decades in the US. ‘Pills’ or, more accurately,
‘tablets’ and ‘capsules’, are described as products of manufacturing, as means of enhancing
personal capacities and as objects in exhibits. In particular, I analyze the underside of pills—their
‘side’ effects—in relation to fears and desires characteristic of contemporary US culture.

Keywords material culture, personhood, pharmaceutical industry, psychopharmacology

What is a ‘pharmaceutical person’?1 I began to wonder about this strange phrase—a person
who is somehow pharmaceutical?—after seeing an educational film produced by American
public television, called Drugs in Our Culture. The film was made in 1967, some years
before the US ‘War on Drugs’, which began with Richard Nixon in the 1970s. Today the
film seems remarkable because it deals with legal drugs (such as alcohol or prescription
tranquilizers) and illegal drugs (marijuana or LSD) in an even-handed way. Near the begin-
ning of the film, a psychiatrist questions the increasingly wide availability of both kinds of
drugs.
Here I will follow the ‘chemicals’, as the psychiatrist in the film called them, specifically
psychotropic drugs that have become available by prescription in greater and greater num-
bers. I will explore his question: ‘What kind of a person would we be when . . . the only way
we can cope with situations is through a chemical?’ I will also place his answer—‘Then
we’re not really much of a person . . .’—into a broader and more contemporary context.
To do this, I will need to traverse a broad landscape, beginning with the recent history of
prescription drugs, and looking at ‘pills’ or, more precisely, ‘tablets’ and ‘capsules’, through

Emily Martin teaches anthropology at New York University. She is the author of The woman in the body: A
cultural analysis of reproduction (Beacon Press, 1987) and Flexible bodies: Tracking immunity in American culture
from the days of polio to the age of AIDS (Beacon Press, 1994). Her current research on cultures of the mental will
appear in Bipolar expeditions: Mania and depression in American culture (Princeton University Press, forthcoming).

1 I am indebted to colleagues who helped me during my crash course in material culture, especially Fred Myers and
Haidy Geismer. Thanks to Richard Cone and Don Kulick for helpful suggestions, and to Joan Bielefeld for phar-
maceutical materials. Readers who would like to see the visual images used in the lecture should email the author
at em81@nyu.edu. Many thanks to David Napier for organizing the British Museum Lecture through University
College London.

273
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274 j E M I L Y M A R T I N

the recent ethnographic fieldwork I have been doing with advertisers, marketers, consumers
and physicians. I will argue that the psychotropic ‘pill’ is regarded both as a kind of living
person and at the same time as an inanimate object. In both its guises, the pill is regarded
with ambivalence. The ancient Greeks had a word, ‘Pharmakon’, which meant both remedy
and poison.2 My purpose is to provide an ethnographic description of the American Phar-
makon. I am interested in the forms of ambivalence that surround it. Here I take ‘ambiva-
lence’ to mean that people surround the same object with two sets of social meanings—
one positive and one negative. The positive meaning sits uneasily with—and is shadowed
by—the negative meaning. I will ask: how do people keep ambivalence about drugs at
bay enough to take them in the massive amounts that have made the pharmaceutical
industry so huge and profitable, increasing many-fold in the last decade alone?
Exploring this question will lead me to certain forms of displacement. Here I take ‘dis-
placement’ to mean a social process by which the dangerous parts of an object are removed
from direct view. In the American Pharmakon, pills are split into good and bad parts: the
bad parts with their negative meanings can thus be displaced to the side and kept out of
awareness, or so it might seem.
The setting for this ethnography is the contemporary US. In this country extreme forces
have been unleashed. The role of the US government, according to the policy-makers now in
control, is to establish strong corporate and private property rights, free markets and free
trade. The government should ensure the free functioning of markets, and expand or extend
markets to areas such as education, the environment or social security. But the government
should not provide social safety nets that would protect individuals whom markets exclude
or defeat.3 In this environment, the individual is responsible for his or her own success or
failure in a high-stakes and ever-changing set of arenas. The person now seems to be
made up of a collection of assets, as if he or she were the proprietor of the self as a stock
portfolio. Accordingly, American children, teenagers, and adults are doing many things to
develop their mental capacities in specific ways, taking on self-management practices, often
seeking to help themselves by using mind-enhancing drugs.

What is a ‘pill’?
I begin with the question, ‘What is a pill?’ During my fieldwork, I was able to interview two
managers in charge of production at a major pharmaceutical company. These men were
responsible for the actual manufacturing of the company’s products: the largely automated
manufacturing processes that compress chemicals into tablets or insert them into capsules.
Production managers work at the juncture between scientists in their research labs, who
design molecules, and marketers, who design advertising and sales campaigns. At the begin-
ning of the interview, I naively used the term ‘pills’. The managers corrected me on the spot:

Pills are made by hand, and no one makes them any more. Tablets and capsules are
made mechanically. Most drugs start out as capsules, then later they become tablets,

2 Derrida has famously pointed out how the Pharmakon ‘introduces itself into the body of the discourse with all its
ambivalence’ (1981: 70). I am indebted to Natasha Schull (2004) for her use of the Pharmakon in relation to video
gambling and psychopharmacology.
3 For the history and development of neoliberal ideas and policies, see Harvey (2005), Rouse (1995), Strathern
(1990).
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T H E P H A R M A C E U T I C A L P E R S O N j 275

which are less costly to produce, and are made with binders so they will be impervious
to moisture and other environmental factors.

I only mention this terminological issue in passing to introduce from the start the physical
qualities of what is being discussed. The material history of the tablet makes an important
starting point for my argument: the technology for forming compressed tablets, developed
in the mid nineteenth century in England, was directly modeled on the technology for
making lead bullets, shot and balls for firearms (Foley and Belcastro).
For the ancient Greeks, the Pharmakon could mean life or death, a remedy or a poison;
for those of us who take modern tablets, they can enhance life, but they are also indebted to
the technology of death.

Making pills persons

Continuing the story of the pill, let us turn to the moment when a prescription drug is just
about to be launched as a commodity on the market. I spoke with the CEO of a small adver-
tising agency that specializes in pharmaceutical products. He told me that the key concept
he uses in pharmaceutical advertising is ‘the core-brand idea’:

We want to get an idea of, if this drug was a person, what kind of person would it be?
What would they look like, what do they feel like?
Is it a woman, is it a man, how do you see it? . . . when Hillary Clinton was popu-
lar, when the Clintons first got in, I must have sat with two clients for drugs and both
of them wanted [their drug] to be Hillary Clinton. Well, a woman who’s strong and
tough and knows what she wants to do, and yet sensitive to social issues . . . all those
kinds of things fit a drug that works really well, but also gives that feminine sort of
feeling to it, too.
If somebody has a big side-effect profile . . . maybe they’re strong but they’re not
gentle. A drug that is everything to everybody, maybe their personality is the gentle
giant. Or one is just not that effective but it’s very easy going and it has a nice way
and maybe you don’t need all that extra efficacy. . .. One is fast-acting and
strong . . . it’s tough and it’s strong but it’s not gentle on you. . .. There are so many dif-
ferent ways that one can go.

Drugs do go in many directions with their different personalities. Another pharmaceuti-

cal marketer summarized in an email the importance of investing drugs with specific
personality traits, which could, in due course, be combined with each other:

The antidepressants in particular have capitalized on [different] effects or lack thereof in

their competitive branding campaigns. ‘All the efficacy without losing sleep, sex, etc.’
One psychiatric group (at Massachusetts General Hospital, Boston) even offers their
patients a ‘menu of reasonable choices’. This is a descriptive ‘menu’ of all the antidepres-
sants they could prescribe along with a description of the various side-effect and efficacy
profiles. This is as close to selecting a pill based on its personality as I can think of.

But investing a pill with personality is only a small part of an advertising campaign for
a psychoactive drug: eventually, the design of the tablet or capsule, the materials given to
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physicians, to patients, posted on the web, aired on TV or printed in magazines are all designed
to connect with the potential consumer, who is depressed, or bipolar, or anxious. In the US,
this concern has greatly intensified with the prevalence of direct-to-consumer (DTC) advertis-
ing. The US is the only country besides New Zealand that permits DTC ads, and US prime-time
television is now inundated by them. As any current DTC ad on American TV makes plain, the
overwhelming emphasis is on how the pill, whether thought of as person-like or not, can make
the consumer a better person, an enhanced person or, more precisely, more like the person they
really are without the interference of a mental disorder. So overwhelming is this emphasis that
the personality of the pill per se gets lost in the face of it.

Life with drugs

If drugs, like other commodities, are given the particular kinds of life I have just described
through marketing and advertising, how do people who take the drugs make sense of this
thing that literally takes up residence inside them? Does the drug seem alive to them the
way a person or a spirit would be? Does the personality advertisers intend to create for
the drug take hold in their imaginations?
Before tackling these questions, it is important to remember that psychotropic drugs
are commodities and, as such, carry a price. Who can afford to buy them? Who has
knowledge to use them? Who has access to physicians or others who can monitor their
effects and suggest adjustments? In the US, these basic questions are determined mostly
by where one is in the hierarchy of resources. In the US, the differences between the top
and the bottom of the hierarchy are extreme. At the high end of the scale, a psychiat-
rist in New York City told me that her patients commonly answer their cell phone calls
during therapy sessions with her. One patient answered her cell phone during a session
and said proudly into the phone, ‘I am with my psychopharmacologist.’ The psychiatrist
commented, ‘I feel like a Prada bag; everyone who is anyone has to have a psycho-
pharmacologist if they want to be with it.’ At the low end of the scale, many of the less
well off people I met in my fieldwork, who needed many psychiatric pharmaceuticals,
were limited by Medicaid (government assistance) to seeing a doctor for 15 minutes a
month.
As demonstrated, one main goal of DTC drug advertising is to invest the drug with a
personality. When people talk about the experience of taking drugs, however, the drug
frequently does not survive with its own intended identity intact. Rather, the drug goes in
the person, and a new person results. A woman spoke out at a support group for bipolar
disorder that I attended as part of my fieldwork:

I am Hanna and I am manic-depressive. I am a rapid cycler, I am either up or down,

and I am not much in the middle, or at normal (if you want to call that normal). I
realize I expected the pills to manage the manic depression, and now I see I need
to manage it at all levels, including the spiritual. I need to learn more, to
exercise more, to be active not passive. My shift in thinking is due to taking
Depakote—it is like a new suit of clothes! I am a snake who has shed its skin, I am
all new and shiny.
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T H E P H A R M A C E U T I C A L P E R S O N j 277

One young woman I interviewed described her deep dislike of switching drugs because
switching changes one’s identity and threatens the ‘magic’ of the original drug:

If I take a new drug, even a new brand name of the same drug, like a different version
of the same drug, I have to reshape my entire identity, like now I am not that person
who took Depakote. If I have to go and take lithium, then I have to come up with an
identity that takes lithium, and that’s a lot of work for me, that’s something I have to
get used to, and so I have an aversion to doing it. It’s the work of producing a new
identity, it’s like integrating something new into your old identity. This is a lot of
work, and for what? It takes away from the magic of the first drug. And if the first
one worked for you, then it has magical properties. You can only be cured if your
medicine has a power beyond being medicine, well, beyond being a drug—that’s
what makes it a medicine instead of a drug, it’s like the magical properties that I
associate with it.

This woman’s notion of ‘magic’ made the drug sound like an impersonal force, but occa-
sionally others spoke of drugs in ways that seemed to give them human-like qualities. An
older woman told me she insisted to her doctor that she wanted to take the anti-
depressant Zoloft, because (holding out her hand as if to cup the pill) ‘it was like a little
robin’s egg, it has that blue color and it represents hope’. In this instance, which stands
out from the usual way people spoke of their drugs, she did see Zoloft as alive—like a little
robin’s egg—filled with hope. For some people, their pills are ‘animated things’, ‘intelligent
objects’, both ‘material and mindful’, to borrow Susanne Küchler’s felicitous phrases (2005:
209, 55).
Some people insisted that the specificity in the design of recent psychotropic
drugs adds to their potency. The young woman I quoted earlier compared her aversion
to the ‘old drug’ lithium with her attraction to the ‘new drug’ Depakote, which
she was taking for bipolar disorder. She called lithium a ‘poison’. She said that
Depakote has

. . . less stigma and also more of this, like, specificity. It’s more specific. It’s
tailor-made for me and my disorder, it’s tailor-made for me and my disease and
only for me and my disease and using my drug to treat some other thing takes away
from—once again—the magical specificity property that it’s going to uniquely
help me.

Specificity was a trait many people valued in their drugs, a trait that they thought
enabled the drug to produce one but not another particular mental capacity or state.4 At
a support group meeting, a woman said that she was off for the summer from her job as
a guidance counselor for the public schools. Her doctor had her taking drugs five times a
day. She had the bottles all lined up on the counter with her pillbox and it was quite some-
thing to get it all straight. Because of her continuing depression, the doctor had added an

4 Marilyn Strathern (2004) connects the advantage that is currently gained by specificity in pharmocogenomics to
Western cultural concepts of the ‘whole person’.
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278 j E M I L Y M A R T I N

additional dose of antidepressant, Effexor, at 4 o’clock. The last drug she takes before bed is
another antidepressant, Seroquel:

I like the last dose of the day best of all, that is the Seroquel. I like the calm, drowsy
feeling it gives me, and I sleep very, very well. But now I am having trouble making
decisions. Before I never had this problem—like at restaurants I would always know
what I wanted to eat. But now I am thinking I need some pill added to help with
my decision-making.

Seroquel does a good job making her calm and drowsy before sleep, so it makes sense that
there might be another drug to help her make decisions.

Pill cocktails
This woman was taking what is called a pill ‘cocktail’. A pharmaceutical marketer
explained the cocktail to me:

Psychiatrists have reacted to these branding campaigns in a curious way. Instead of

prescribing one antidepressant or the other, they combine the drugs into their
favorite ‘cocktails’. In LA, one drug combination became so popular it is called the
Hollywood cocktail. It’s popular because it utilizes Serzone (somewhat sedating, yet
without weight gain, sexual dysfunction, sleep loss) and Effexor (activating, pep-
you-up so you can ‘get out of bed in the morning’). This hyper-management of symp-
tomatology to a state that is better than normal or baseline seems like a new kind of
medicine. In the case of the Hollywood cocktail, the psychiatrists are actually inducing
a sort of mania or hyper-alertness (at least compared to the person’s previous state).

Physicians’ readiness to combine the character traits of drugs to optimize a patient’s

mental state should alert us that, however person-like they may seem, drugs are not exactly
like persons. Their personality traits are more thing-like than person-like because they can
be bought and sold and combined on demand in many ways, more like the parts of a motor
or the ingredients of a cake than the personality traits of people.
Postings on web newsgroups for bipolar disorder make it immediately apparent how fre-
quently people are taking complex bundles, ‘cocktails’, of drugs that they try to adjust to
ease new symptoms, side effects or drug interactions. Here is an extract from a newsgroup
posting:

I have been diagnosed with bipolar for about 3 years now, before that they were just diag-
nosing me with mood disorder, chronic depression, anxiety, and personality disorder.
My current meds are:
Wellbutrin SR = 300 mg daily
Lorazapam = .5 2x daily
Tompamax = 200 mg daily (just reduced from 400 mg daily)
Depakote = 250 mg AM
Depakote ER = 1000 mg PM
Lithium = 600 mg daily
Seroquel = 50 mq daily
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T H E P H A R M A C E U T I C A L P E R S O N j 279

We’re currently playing with my meds again trying to get me stable once more, I’m
a rapid cycler, and had a pretty quick cycle into high and then dropped out to a
long-lasting low that caused some problems.5

Doctors’ cocktails
In my fieldwork, the strategy of combining drugs into cocktails in pursuit of fewer side
effects and fewer symptoms was a commonplace topic during informal discussions among
doctors. I was able to get concrete details about the ways physicians talk about managing
patients on drugs through web forums set up (by pharmaceutical companies) for doctors
to raise questions about medicating their patients.6 For reasons of confidentiality, I call
the drug that is the focus of the website ‘Drug R’.

This doctor describes a patient experiencing significant thirst:

I’m treating a woman in her 40’s for depression and panic disorder. She may have a
subtle bipolar illness. She is currently on lithium carbonate 1500 mg a day, Drug R
45 mg a day, Depakote 625 mg a day, Klonopin 0.5 mg TID [three times a day]
and Pamelor 50 mg a day. (27 Jan. 2000)

Another describes a similarly complex regimen that is still not handling the patient’s
depression:

Male 37 years old with previous documented sexual abuse as a child, current diag-
noses: DID [Disassociative Identity Disorder], ADHD, PTSD [Post-Traumatic Stress
Disorder], bipolar II with refractory depression . . . current meds: lithium 1200 mg,
Lamictal 200 mg, Effexor 450 mg, Drug R 45 mg, Cytomel .25 mcg, Ritalin 80 mg.

When the patient recently became hypomanic, the doctor decreased his Effexor, Ritalin and
Drug R, but in three days, he again had the ‘most malignant depression I have ever treated’.
Not all postings received a response, but this one did. The consulting online doctor replied,
‘With this understandable and heroic combination of meds, what to do? I suggest adding
another mood stabilizer (Depakote or an atypical antipsychotic Olanzapine)’ (12 May
2000). When drugs are causing problems, the solution is more drugs.
When I started this research, perhaps seduced by the marketing literature I had read, I
imagined that people would invest their drugs with personalities and form some kind of
relationship with them, perhaps seeing them as encouraging companions, calming presences
or strong protectors. My expectations led me to look hard for such relationships. What I
actually found was that patients personify new, high-tech drugs only weakly, and do not
usually invest them with elaborate symbolic value of a person-like sort. Both doctors and
patients see drugs as precision instruments that would precisely excise suffering if they could
only find the right combination. So perhaps we should say that a different set of ideas is at

5 http://www.livejournal.com/talkread.bml?journal=bp_disorder&itemid=85520 06/26/02
6 An employee in a firm to which pharmaceutical companies outsource their publications graciously gave me a pass-
word to the forum. The location of the site is confidential.
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280 j E M I L Y M A R T I N

work here, ideas about the potency of precision-engineered molecules. The work of Nikolas
Rose helps us understand this. He has pointed out how the ‘ ‘‘molecular’’ dissection of
pathology’ affects the design of drugs: because the new antidepressants, for example, pur-
ported to be drugs ‘whose molecule had been deliberately fabricated to disrupt one, and
only one, aspect of a single neurotransmitter system’, Prozac could present itself as:

. . . a smart drug, a clean drug, which did not produce all those unwanted effects—
shuffling gait, dry mouth, tremors—produced by the earlier clinically derived ‘dirty’
antidepressants, which hit a number of sites [different receptor molecules on different
neurons] in a number of systems at the same time. The dream, that is, is of drugs that
do not act upon the person as a whole, but are targeted precisely to correct a specific
anomaly.

It follows, as Rose perceptively goes on to say, that individuals are now obliged to take
responsibility for picking and choosing (so it seems at least) among these precision instru-
ments, to optimize their capacities and flexibly adapt their brains and minds to the changing
environment. In 1967, the psychiatrist in the film I mentioned earlier could say ‘we’re
not really much of a person’, if we require taking chemicals; today we are less of a person
without them.
How can such a premium placed on technical precision be reconciled with the invest-
ment in making a drug like a person? It all depends on how you look at it. From the point
of view of research and production personnel, the preoccupation of sales, marketing and
advertising personnel with the aesthetics of the tablet was understandable but rather trivial.
Their own work on the drug’s chemical formulation was like building the ‘body’ of the
drug, and the rest was its ‘dress’. In a manner reminiscent of Lynn Meskell’s description
of the ancient Egyptians dressing their divine statues, the production personnel would coop-
erate in making this ‘dress’ comforting and comfortable, stylish and aesthetically pleasing,
even though (unlike the Egyptians) they found the effort superficial in comparison with
building the body of the tablet itself (2004: 55).

The pill as art object

Clearly the pills, tablets and other medicines captured in the exhibit7 are framed as objects
of both art and scientific craft. This is a startling way to frame pills, and it calls to mind
Danny Miller’s insight that ‘frames such as art galleries . . . ensure that we pay particular
respect, or pay particular money, for that which is contained within such frames’ (2005: 5).
Pills and capsules are arranged like gems in a jeweler’s display case; they are laid out like
exotic insects in an entomologist’s collection. This is truly a pharmaceutical cornucopia.
Although the exhibit in the British Museum is the only one of its kind, it has a precursor.
The Physicians’ Desk Reference, on the desktop of virtually every American physician,
also displays pills, tablets and other medicines in a photographically realistic manner. The
drug photographs are arranged in groups, organized by the pharmaceutical corporation

7 The exhibit referred to is ‘Cradle to grave’ at the British Museum (see http://www.cradletograve.org).
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T H E P H A R M A C E U T I C A L P E R S O N j 281

who produces them, and these photographs are printed at the beginning of the remaining
3,000 plus pages of the manual.

Miniaturization
Is part of the appeal these displays have for us that the pills are miniature containers of
something potent? In The Savage Mind, Claude Lévi-Strauss wrote about the effects of min-
iaturization in art, using Clouet’s portrait of Elizabeth of Austria as an illustration. ‘The
highly realistic, thread by thread, reproduction of a lace collar’ arouses in us a ‘very pro-
found aesthetic emotion’, which, Lévi-Strauss speculates, arises from miniaturization. While
science often produces knowledge by breaking wholes down into parts, art proceeds by
creating a homologue of the whole, but one quantitatively diminished. To depict Elizabeth
in miniature or, indeed anyone in miniature, ‘demands an intimate knowledge of its mor-
phology and technique of manufacture’. By means of this knowledge, the collar can be
depicted ‘exactly as it is’ but simultaneously only as it is from one particular perspective.
Our power over what is represented is increased: we can grasp, assess and apprehend it at
a glance. A child’s doll ceases to be ‘an enemy, a rival or even an interlocutor’. By becoming
miniaturized, the person the doll represents ‘is made into a subject’ and those of us who play
with the doll become its master. Of course, this may be an illusion, but it is an illusion we
enjoy because it ‘gratifies the intelligence and gives rise to a sense of pleasure’ (Lévi-Strauss,
1966: 22–5).8
Alfred Gell also had interesting things to say about miniature objects. In a well known
article, he recalled that as a young boy he was taken to see Salisbury Cathedral, where, in
a side chapel, he found a small-scale model of the cathedral, complete in every detail, con-
structed entirely out of matchsticks and glue. The model (unlike the cathedral itself) struck
him with the ‘deepest awe’ (Gell, 1998: 47). Gell’s argument is that, as the viewer perceives
the technical difficulty of making such a model, he is stunned into astonishment, imagining
the object to be filled with enchantment. For Lévi-Strauss, the miniature gives us a sense of
power over it, for Gell, the miniature, if complex enough, strikes us into submission. Tech-
nical processes ‘cast a spell over us so that we see the real world in an enchanted form’ (Gell,
1998: 44).
Can either of these theories be applied to tablets and capsules? There is an important dif-
ference between miniatures and pills: the internal parts of the pill are not visible. Sometimes
capsules are transparent and we can see what is inside, but what is inside simply looks like
more pills. The complexity and technical prowess contained in the pill exists at the molecu-
lar level. In fact, pills defy recognition of their complexity in an important way: they look
like sweets. In some cases, the technology of making tablets and sweets is the same; in
some pediatric formulations, pills are marketed in the exact form of sweets. Depakote
‘‘Sprinkles’’, for pediatric use, look exactly like the candy called Hundreds and Thousands
(or Jimmies). Depakote is given to children with seizure disorders, so there are legitimate
reasons to make such life-saving medicine look palatable to them. Still, pills as sweets can
be seen as a disarming idea. So perhaps in the case of pills, their diminutive, innocent

8 For another view of miniaturization and its effects, see Stewart (1993: 364–6).
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282 j E M I L Y M A R T I N

form disarms us rather than enchants us. They become innocent confections, and we
become their masters.

Side effects
Miniaturization plays another important part in our interactions with prescription drugs,
but we need to look sideways to see it, by focusing on the side effects. Why ‘side’ effects,
and what do they have to do with miniaturization? In the case of Lunesta (a sleep aid),
the size of the package is dwarfed by the size of its package insert on ‘side effects’. This
might seem obvious and unproblematic: we want the main effect, sleepiness; we don’t
want the ‘side’ effects that might come along with sleepiness, and that’s why they are
over on the ‘side’. Nonetheless, it is a short step from side effects to ‘collateral damage’, a
phrase used by the military for the unintended consequences of military actions, which
should remind us of two things I have mentioned: the same machinery was used for making
both bullets and pills; the Greek word Pharmakon could mean either remedy or poison.
Let me say before going further that every detail of the depiction of side effects in the US
is governed by Food and Drug Administration regulations, or at least by those regulations as
they are interpreted by pharmaceutical companies. The size of print on advertisements and
the amount of information in advertisements are features that the FDA tries to dictate. DTC
advertisements have an aural equivalent of the ‘fine print’: quickly voiced, monotone recita-
tions of side effects at the end of ads, which the FDA regulates for loudness and speed.
To use the Lunesta packaging as an example, at the forefront there is the advertisement
copy, with its sparse language and carefully engineered images, and on the side there is the
full statement of side effects in a minuscule type font. At the forefront, there are words and
images that are designed to capture our attention by engaging our senses and desires; on the
side, there are words that are not really meant to be read or heard. Even the paper on which
the side effects are described seems fragile, insubstantial, so thin it might tear, so crinkly it
might shatter, folded up so tightly, it might never come undone. I believe this is the prover-
bial ‘fine print’: the part of a contract that, one hopes, the client will not bother to examine.
Recall Lévi-Strauss’s argument about the power we feel over miniatures. Bruno Latour has
made a related point about the use of scale reduction in science to control resources in the
environment (Latour, 1987). When explorers entered new lands, made maps and brought
them back, they made important features of the distant landscape portable: the reduction
in scale enabled them to gain power over distant places: they could shrink the distance
between home and distant shores by shortening the time subsequent travelers needed to
make the same trip. ‘A cycle of accumulation . . . allows a point [for example London] to
become a centre by acting at a distance on many other points’ (Latour, 1987: 222). A
map, reducing distant lands to a shape on paper, is a ‘stable’ and ‘mobile’ element that
allows a ‘centre to dominate faraway lands’ (1987: 224).
I want to reverse the direction of Latour’s example and join it synergistically with Lévi-
Strauss’s. If a map serves to harness the resources of distant shores and make them more
accessible, the reduction in scale of the small print could serve to harness the information
we have about drugs and send them far away. The ‘mobility’ of the miniaturized element
allows it to move in more than one direction; its ‘stability’ keeps its contents intact. The
power is the power to displace and remove by means of a reduction in scale. Just as the
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doll becomes the little girl’s ‘subject’ in Lévi-Strauss’s analysis, the ‘side effects’ become the
drug’s ‘subject’, and can be banished to the sidelines. This is a form of displacement. Just
as Latour’s distant places are reduced in scale, made mobile and transported closer, the
‘side effects’ are reduced in scale, made mobile and displaced farther from the center of
consciousness.

Black boxes
An important part of drug regulation in the US is the ‘black box’ warning.
A black box warning is the most serious warning the FDA can give to consumers about
harm a drug might cause. The phrase itself—‘black-box warning’—is so common that
Americans, including me, have failed to ask what the words mean. This might be an exam-
ple of what Danny Miller calls ‘the humility of things’, their capacity to ‘fade out of focus
and remain peripheral to our vision and yet determinant of our behavior and identity’
(2005: 5). But a moment’s reflection brings to mind other meanings of a ‘black box’: in engi-
neering and computer programming, black-box testing is used to check that the output of a
program is as expected, given certain inputs. The term black box is used because the actual
program being executed is not examined.
What is not being examined in the case of pharmaceuticals? First we have to understand
that pharmaceutical companies resist black-box warnings for fear they will affect sales
adversely. Correspondingly, consumer advocates who believe existing warnings are insuffi-
cient or inaccurate because they do not capture newly revealed ‘adverse effects’ will lobby
the FDA to require a black-box warning. Mediating between these forces, the FDA makes
it plain that it can demand a black-box warning from the company: otherwise the FDA
can withdraw its approval of the drug.

Bad objects
What intrigues me is that Americans (including me) actually put these objects (in great num-
bers) in our mouths and swallow them. We take them into our bodies and our minds. And
we do this, routinely, with all the disturbing ‘side effects’ right there, but hidden in plain
sight. The phrase is Freud’s, and one of Freud’s students, Melanie Klein, expanded on this
idea. Klein developed a set of concepts for describing how people handle relationships
that disappoint them. Children, wishing naturally for all their needs to be instantly
met all of the time, are inevitably disappointed. To handle their anxiety, children first pro-
ject these bad feelings onto their parents and then internalize a representation of their par-
ent, in which the ‘badness’ is contained inside the representation of the parent but lodged
within themselves. The children thus gain some control over the anxiety-provoking badness,
but at the cost of infecting themselves with badness, one might even say with ‘poison’.
This Klein called a ‘bad object’. Eventually, as children mature, they might learn that the
‘badness’ was in their mother, a person separate from themselves, not in themselves, and
that the mother’s ‘badness’ was inevitable for any parent (for useful accounts of the Kleinian
tradition see Greenberg and Mitchell, 1983; Hinshelwood, 1994).
Now, consider one of these drugs as an internalized ‘bad object’. The caring and nurtur-
ing sentiments in the advertisements, offering us everything we want—sleep, social ease,
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potency, pleasure, happiness—are, we know at some level, disappointed before we swallow

them. But swallow them we do, and now the ‘bad object’ takes up residence inside us. If we
follow Klein, the goal of maturity is to realize that the ‘badness’ lies in the way of the world,
not just in us and not just in the Pharmakon’s particular failings. Maturity also lies in the
realization that no one could satisfy all our needs and that we will survive this realization.
This is only an analogy of course. The corporation that makes the drug is not a parent.
But something potent resides in the drug, something that makes us not want to think about
the harm it can do. I would suggest that contemporary pills, clean, pure and precisely engi-
neered as their scientific ‘body’ may appear to be, also have a blood-stained, fleshy ‘body’.
They acquire this second body during the process of clinical trials.
Adriana Petryna has shown that the growth in ‘the number of people participating in
and required for pharmaceutical clinical trials’ has become massive’ (2005: 183). Many of
these new trials are being conducted in low-income countries where people are, therefore,
relatively willing to participate in trials for monetary compensation.9 Moreover, such sub-
jects are much less likely to complain about side effects. Many other forces are also pushing
this expansion: the post-Second World War boom in production of pharmaceuticals in the
US; the increase in government regulation and oversight of the industry in the US (including
the ban on use of prisoners for clinical trials in the 1970s); and ‘treatment saturation’ in the
US. ‘Treatment saturation’ means that the affluent people in the US are using so many drugs
that drug–drug interactions interfere with the ability to recruit subjects for these trials.
Hence, clinical trials have increasingly been conducted outside the US. The statistics in the
miniaturized list of side effects are from these (probably far away) people, who were harmed
by the drug.
This statement might seem to contradict my earlier argument that we do not see the fine
print. But I think we both see it and do not see it. The bloodstained body of the drug is so
dangerous and frightening that we want to push it away altogether, but it hides in plain
sight in the side effects. Behind the clean, molecular body of the pill is the injured flesh
and blood of bodies that haunt both consumers and producers and will not haunt them
quietly.

Corporate persons as externalizing machines

I now turn to another aspect of why the fine print is hidden. Drugs are products of corpora-
tions, and corporations are profit-making organizations. Historically, the corporation was
granted the legal status of a ‘person’ in the US in the late nineteenth century. In his book
(and film), The corporation: The pathological pursuit of profit and power, Joel Bakan takes
the corporation’s status as a person seriously.
Bakan posits that the US corporation’s behavior as a ‘person’ in the present economy fits
perfectly the psychiatric definition of a psychopath. The corporation’s only legitimate man-
date is to exploit others for profit; people are treated like tools that can be used, depleted
and thrown away. Its mandate is to dehumanize. Bakan cites a prominent US businessman,
Ray Monks, who stated that ‘the corporation is an externalizing machine’ (2004: 69, 70).

9 Petryna documents how pharmaceutical corporations change the ethical standards they use in different places to
achieve cost-effectiveness, parlaying ‘cultural differences’ into a way around universal standards (2005: 184–5).
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In the terms I am using here, the corporation is displacement machine. Much of the corre-
spondence between pharmaceutical companies and the FDA, available to the public on
the FDA’s comprehensive website, is a tug of war over what the companies can displace
into thin air (that is, omit from package inserts) and what they can only displace into the
fine print or black boxes.

The shadow
Users’ accounts of drugs are permeated with ambivalence—simultaneous and contradictory
feelings of attraction and repulsion. The drugs help me, they hurt me, they ease one kind of
pain and intensify another, and they take away one painful symptom but add a new one. It
was to my astonishment, then, that I witnessed a display at the 2000 American Psychiatric
Association that depicted the worry patients feel (some of which is surely legitimate) as a
literal form of paranoia. This display, liberally branded with the logo of Risperdal, a major
prescription antipsychotic from Janssen Pharmaceutica, was a virtual reality set-up called
‘Virtual Hallucinations’.10 Physicians stood in line reading an information card explaining
what was to come. Meanwhile, overhead, a video on continuous loop featured a man
diagnosed with schizophrenia telling us that the experience we were about to have was
true to life.
After a long wait, I reached the head of the line, went to my assigned station, and put on
my headphones and helmet. This gear would provide the sight and sound for me to experi-
ence a virtual world. The attendant instructed me, ‘When you enter the pharmacy, look
around, and keep looking around to find the pharmacist.’ As the virtual scene unfolded,
the narrator told me that I was a patient who needed her antipsychotic medication, but
my prescription had run out. So my friend, a woman, had brought me to the pharmacy to
get a refill. As my virtual experience developed, my friend and I entered the pharmacy
door. Just inside, the friend turned around and said, ‘I’ll be back soon; you will be all right,
won’t you?’ She then vanished rapidly out of sight into the back of the store. The virtual rea-
lity narrator directed me to look around for the pharmacist. I saw people in the aisles who
seemed to be there one minute and gone the next. The sound was echoing and distorted.
Objects and people sped through space in a blur. Voices came from everywhere, and some-
times specifically from the people I saw. A woman in the aisle looked at me suspiciously
with a hateful expression. As I made my way to the back of the line to wait for my prescrip-
tion, the virtual reality narrator provided the script of my thoughts: ‘The pharmacist does
not want me to have the pills; he is going to do something terrible; he is going to call the
insurance company and this will put me in danger. Who can tell what the consequence
might be?’ I felt frightened and wanted to flee. As I watched him prepare my medication,
the prescription bottle became a bottle of poison with a skull and crossbones on it. The
dissonant music and disturbing special effects made this terrifying prospect the dramatic
culmination of the experience.
The intended message of the display was that paranoia is a well-known symptom
of some psychotic conditions and that the drugs the virtual pharmacist was preparing can

10 This technology has since been marketed as an educational device called ‘Paved with fear’.
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alleviate this symptom. The patient, however, could have been frightened of any number of
strange things that happened in the virtual scene. What the patient feared most intensely
was the pharmacist and the drugs he was preparing! The obvious message is that the patient
has irrational, paranoid fears of the pharmacist. But the obvious message overlays another
darker one: the reason the patient fears the pharmacist and his drugs is because the drugs
are poison! The association between feelings of paranoia and schizophrenia is well accepted:
what is extraordinary is that Jansson Pharmaceutica, surely despite its own interests as
makers of Risperdal, a major prescription antipsychotic, portrayed a prescription drug for
schizophrenia as a bottle of poison. Social knowledge, displaced by side effects in fine print
and hidden in black boxes, erupts here into the open. So the bad side effects of their drug are
merely a hallucination of the psychotic patient.

Conclusions
To follow what is happening in this milieu, one must be attentive to displacement. Bad
effects of drugs are displaced into the fine print and into black boxes. Adverse effects
from clinical trials are displaced onto Third World populations. Corporate knowledge
that pills, like the Pharmakon, are poison, is displaced onto the paranoid schizophrenic.
How can a person tolerate all this and still manage to ingest these ‘bad objects’? I return
to the statements of my interlocutors who depend on the drugs’ good effects, alone or in
cocktails, to keep working, parenting, studying or just living. I am arguing not for cessation
of this ingesting, but for something like what Melanie Klein and her followers offered their
patients: the insight that maturity involves recognizing that the ‘bad’ part of the ‘bad object’
can be pictured as part of the external world and does not need to be displaced into the hid-
den interior of an individual. With respect to pharmaceutical products, we could learn to
acknowledge that they contain the blood of others spilt in clinical trials, despite the polished
image, the careful ‘dress’ they are given in advertising. What would happen if the knowledge
American consumers hide from came out into the open, for public discussion? More consu-
mer activism? Deeper awareness of bioethical issues?
This suggestion is tricky because consumers are already openly discussing the compara-
tive side effects of different drugs. These discussions are widely available on the web and
they are also deliberately elicited in the focus groups drug companies organize. Rather
than leading to open discussion, such material can simply be used in more sophisticated
marketing: drugs can be sold competitively on the basis of their comparative side-effects
profile.
This could not be the end of the story, however. When even powerful pharmaceutical
corporations cannot stop themselves from imaging their products as poisons, bringing hid-
den truths to light, how much more so will consumers be unable to ignore indefinitely the
displacements I have described? To return to my starting point, the physical materiality of
the pill, recall that the same technology that made bullets was also used to make tablets.
Could tablets finally become less like bullets (or poison) and more like remedies? Our phar-
maceutical cornucopia is still, more than we would like to admit, a Pharmakon. Despite the
efforts of the FDA (which can still place some limits on the market), the balance is tilted
towards the corporations who benefit from market forces. I hope the extreme nature of
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the US case shows us that, even under the relentless demands of the almost untrammeled
market, ambivalence, and the dangerous forces it displaces, can never be entirely hidden.
In this there might be hope.

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