The media is replete with accounts of Big Pharma gone bad. A modern Scheherazade could keep herself alive for a thousand and one nights by recounting tales with titles like « Vioxx, » « Risperdal, » « Paroxetine, » and even « Daraprim. » Yet, if the point being made in these accounts is that the pharmaceutical industry has an undue level of political influence with little if any accountability to patients, health care providers, taxpayers, or policy-makers, social scientists and policy analysts have been curiously unwilling systemically to analyze the nature of this power. Anecdotal accounts of individual cases are fascinating in their gritty detail, but they are not particularly helpful in the attempt to understand the systemic dynamics of power underlying the modern pharmaceutical industry. The public shaming of corporations is a limited and capricious approach to solid policy reform. Without a systemic comprehension of why and how these interests are able to exercise power, it remains difficult to address and resolve the problem.
But identifying power relationships is a tricky business. The linear model of clear and demonstrable causality that is the basis of so much scientific thinking is simply not as useful here (and the stipulation of replicability as a condition of proof is even more impracticable). Not all exercises of power are visible; and often « proof » of the exercise of power is not the existence of a palpable and quantifiable object of study, but rather its absence. One of the most sophisticated frameworks for the study of power has evolved in the field of comparative politics and development studies. Here analysts are interested not only in the evident and detectable exercise of power (such as the use of legal institutions, economic clout, or political force to prevent identifiable groups from obtaining their stated objectives) but also in the ability of interests to exclude specific groups or views from entering the political arena altogether, and in the more insidious capacity of interests to lead others to internalize certain values, identities, or lack of self-esteem in order to perpetuate a given relationship of power. A simple hermeneutic developed by John Gaventa is the « power cube, » a means of conceptualizing power on a number of different interrelated dimensions:
Gaventa designed his theoretical framework as a tool for academics and activists « to map the types of power which we sought to challenge, and to look at the strategies for doing so. »1 The three-dimensional model presents the exercise of power as an interrelationship between « spaces, places, and forms of power. » For example, the ability of multinational corporations to benefit from the protection of private property rights being negotiated in international trade agreements is substantially different from the kind of influence they exercise through the ability to stipulate which diseases are best treated through particular compounds; and the ability of an industry to capture the regulatory system is a distinct form of power yet again. The advantage of this multidimensional approach is that it attempts to understand the influence of the pharmaceutical industry in a very thorough and nuanced way: as Dranove and Garthwaite have noted, « lumping all drugs into a single category of ‘good products made by evil firms’ is not only incorrect on its face, it can lead to very poor public policy ».2 Lumping all pharmaceutical firms together is similarly imprudent, as they have divergent objectives, different resources, and dissimilar scope. We need to be able to develop a more sophisticated understanding of the industry as a political player than current accounts present. This means not only examining the political and economic influence of the industry, but also the more ephemeral discursive sphere: what counts as evidence? What counts as disease, or better health? Whose voices are given credence, and whose are delegitimized? How does this occur?
The cross-fertilization of analytical tools from one discipline to another is a difficult undertaking; but useful concepts and ideas can often be adapted with careful reflection. To get from an account of Big Pharma as mustachio-twirling villains to sophisticated interests able to utilize not only legal, economic, and political structures and processes but also social and intellectual ones to their advantage, we need to build a more systematic way in which to understand why it is they can do what they do. Gaventa’s approach is a constructive place to begin.