Reviewed: Quentin Ravelli, La stratégie de la bactérie (“The Strategy of Bacteria”), Paris, Seuil, 2015, 368 pages.
The sociologist Quentin Ravelli got as close as he could to actors and their practices in his search for material on which to base this critical analysis of the pharmaceutical industry and the drugs market. Written in a highly immersive style, this work was the fruit of his thesis research. It invites the reader to follow the commercial and scientific life of the commonly prescribed antibiotic Pyostacine in France, owned by the Sanofi laboratory.
In order to understand how this drugs manufacturer operates, the author sets out to observe it on a daily basis, in the workplace, carrying out its lobbying and organisational work, far from the recent scandals that have hit the profession. The antibiotic analysed has nothing to do with the Mediator or Vioxx drug catastrophes, and the industrial challenge he studies is a routine affair: repositioning Pyostacine, usually prescribed in the field of dermatology, in the area of respiratory infections. To that end, the author shows us how the industrial actor particularly uses the growing phenomenon of resistances to antibiotics as a way of legitimising this “respiratory turn” in the antibiotic’s commercial career.
A commercial biography
The author’s answer to the question that structures his book – how to create value in use – comes in the form of a particularly detailed description of the modes of production used for the sales arguments and power relations at play in this sector, which is saturated with conflicts of interests. Under Ravelli’s pen, sociological material becomes a subject in itself and the style he uses allows the reader, whether an expert or a layman, to immerse himself in the health industry. The reader thus has the opportunity to go inside factories, sit in waiting rooms accompanied by a medical visitor, observe her coded exchanges with a client, learn about the organisation of medical conferences and the staging of scientific marketing, and grasp the way in which these industrial actors operate through an analysis of the structuring of the headquarters and the location of the various services provided.
The reader discovers how competing manufacturers unite to monitor each doctor’s prescriptions: “I realised I was being watched, that they knew exactly what I was prescribing (...). I was naive, I hadn’t realised. [One day], a medical visitor said to me, “You don’t prescribe much!”, and I thought to myself, “How can she know that?” (p. 78). Another telling example of the richness of this book is the description of the way in which Sanofi holds mock competitions for medical internships in close collaboration with university deans, which gives an original insight into the scope and diversity of the range of influential strategies in use in the sector. It is a device that “identifies future influential doctors before they have even identified themselves” (p. 126).
The author offers a “social biography of commodities” constructed at the intersection of the cultural anthropology of James Frazer and Bronislaw Malinowski, the political economics of Adam Smith and Karl Marx, the sociology of work of Michael Burawoy and the sociology of science of Bruno Latour. His stated aim is to make an “extended case study” of major socio-political upheavals in order to understand the “transformations of an economic sector, revealing the advancement of contemporary capitalism” (p. 17). His justification of this theoretical framework and the discussion of authors to which it gives rise explain the political dimension of this work.
His aim is to critique contemporary capitalism by analysing one of its most powerful and visible representations in the public sphere: the pharmaceutical industry. The fact that Sanofi authorised a PhD student in sociology to work in the firm for several months (as an intern), in different departments (marketing, production), to carry out dozens of interviews and use internal documents shows that this supposedly opaque, secret industry can be observed from the inside, albeit under specific conditions. It is regrettable that the author does not expand more, in the manner of the anthropologists to whom he refers, on the conditions in which he was allowed to enter the firm and particularly on the development of these relations following the publication of his thesis and any feedback he may have given to the employees he observed.
His presentation of this reflexive work might have enabled the author to better define his relationship with the subject, his methods of engaging in research and the methodological limitations of this technique of participant observation. The interest of this empirical work – in addition to the high quality of its analyses – lies in the fact that the author had the opportunity to observe a very unique stage in the history of the Sanofi laboratory and, more generally, of the pharmaceutical industry. He shows how two congruent phenomena, the sudden slowdown of innovation in the sector and the proliferation of health crises and lawsuits forced manufacturers to reorganise production and redeploy their strategies for research, marketing and influence. In view of this, one question should have been discussed: how does this publication fit in with the transparency strategy in which this manufacturer and others are currently engaged?
An industry without safeguards
As mentioned earlier, this book is written in an original style. It is clearly aimed at a non-specialist readership as well. The book is divided into three main parts entitled Vendre (Selling), Produire (Manufacturing) and Chercher (Researching), which makes it considerably easier to read and understand this sometimes dense text. The author’s technique of popularising a highly technical and still little-known sphere is not detrimental to the logic of proof. The work is extremely rigorous and brings the scientific community a biography of the market and, by extension, a portrait of the industry that is likely to interest sociologists of work and health alike.
Nonetheless, it seems to us that the division of the book into three parts, no doubt the result of editorial requirements, forces the author to deal with the issue of drugs marketing separately from that of research, which does not help to explain the notion of scientific marketing (Gaudillière & Thoms, 2015). The author is thus the victim of a kind of relativism of exposure when he prioritises the commercial side of the biography of this drug at the expense of a more systematic description of the scientific anchoring of these commercial discourses. The following comparison between wine and medical drugs is a good example: “Although the wine and spirits market has a more scientific singularisation system, the drugs market shares the same uncertainty with regard to quality” (p. 62). After reading part one, Vendre, the reader is left with the impression that there is an extreme malleability of data resulting from clinical research, which would only need to be interpreted, much as one interprets a classical text, in order to identify a new indication and therefore a new market. Playing with words and statistics in this way aids the development of the therapeutic indications of the drug studied, but it would have been preferable to clarify further the conditions of possibility of these interpretations by making a more specific upstream analysis of clinical drug research and its financing.
The third part, entitled “Researching – beyond conflicts of interest”, partially corrects the exposure effect by offering in particular a very enlightening ethnography of the organisation of medical conferences and the stage acting in which clinicians and laboratories engage in order to make their ubiquity acceptable in these scientific demonstrations. It would probably have been preferable to expand this part further in order to clarify the conditions under which clinical data on drugs is produced, by better demonstrating the effects of the large-scale financing of clinical drug research by the pharmaceutical industry. This form of economics, specific to clinical research, makes scientific questioning subordinate to laboratories’ commercial logics and allows the manufacturers to almost completely control their molecules on the scientific agenda (Dalgalarrondo, 2004). Here too, in the author’s words, “the value in use of new antibiotics” is “subject to the economic demands of their exchange value” (p. 19). As such, even though it is perfectly legitimate and relevant to focus on analysing the “commercial gesture” as a source of wealth creation, a more in-depth presentation of the functioning of clinical research, the conditions under which trial protocols are established (choice of comparator drug, duration of the trial, patient profiles, etc.), the dynamic by which hospital clinicians and manufacturers are matched, and the content of the exchanges between these two types of actors would have provided a better understanding of the commercial strategy implemented by the Sanofi laboratory. It is also regrettable that the author did not give a more detailed account of the history of the recommendations issued by academic societies or public agencies (Haute Autorité de Santé – HAS – and the Agence Nationale de Sécurité du Médicament et des Produits de Santé – ANSM) in favour of the “respiratory turn” taken by Pyostacine. An analysis of the professional career of doctors practising in these places of expertise and their links with the Sanofi laboratory would most certainly have given pause for reflection on conflicts of interests.
The pharmaceutical industry has been the focus of increased attention from the social sciences in recent years. Quentin Ravelli’s book makes an important contribution to our understanding of the drugs marketing system, and it reveals the major transformations the sector is currently undergoing. By highlighting the risks inherent to this quest for a share of the market free from any public health imperative, the author rightly reminds the reader that drugs are also potentially “monstrous” commodities sold by manufacturers.
The ethnographical quality of this book gives us a closer insight into the pharmaceutical laboratories’ capacity of influence, which is often condemned but not usually the object of direct observations. Its exposure of the diverse strategies used is supported by the author’s keen ability to reveal details. He reaches firm, critical conclusions: the capture risks for regulatory agencies and scientific communities, as well as the political, scientific and cultural dominance of this powerful actor is clearly presented. His observation is all the more interesting because it was made in a major area of public health: antibiotic treatment. The question of resistant bacteria now benefits from a narrow sociological viewpoint in which the commercial logic of the pharmaceutical industry and its harmful effects on public health are clearly documented.
