BMJ 2007;334:932 (5 May),
Complex problems have depressingly complex causes, and the solutions are often taxing and unsatisfactory
Looking at popular culture, it seems there’s something very attractive about simple biomedical explanationsâ€”and solutionsâ€”for complex social and psychological problems.
Four weeks ago the BMJ published a large randomised controlled trial, with a positive result: it showed that one treatment for children at high risk of developing conduct disorder could significantly improve antisocial behaviour (BMJ 2007:334:678-82). It was a well conducted trial, at multiple sites, with a novel result, on a subject specifically called for by NICE, and it even had a compelling cost effectiveness analysis.
Was this miracle pill reported as front page news in the Daily Mail, natural home of miracle cures and sinister hidden scares? Was it followed up on the health pages, with an accompanying photo feature, describing one child’s miraculous recovery, and an interview with a relieved mum with whom we could all identify?
No. In fact, this story was completely ignored by the entire British news media, despite their preoccupation with both antisocial behaviour and miracle cures, for one simple reason: this was not a story about a pill. It was a cheap, practical parenting programme.
At the same time, for over two years now, the newspapers and television stations have gushed praise on an endless stream of largely unpublished and increasingly melodramatic claims made for fish oil pills in schoolchildren.
This represents an interesting disparity. These fish oil “miracle pill” claims are generally made on the basis of unpublished “studies,” with clear involvement of the multimillion pound pharmaceutical companies manufacturing the supplements, which are presented directly to the media with minimal corroborating evidenceâ€”no published paper, no statistics, and in essence no science at all. My attempts to get further information about the data behind various of these stories for my Guardian newspaper column have routinely been met with polite but firm obstructiveness.
This is in stark contravention of not just every published guideline on communicating research findings to the public, but also a clear challenge to common sense, since there is no meaningful opinion whatsoever, with the best will in the world, that anybody could sensibly hold about unpublished scientific research, reported only in the form of a press release and a tabloid news story.
Now there may yet turn out to be good evidence for significant benefits for children from fish oil tablets (although, in context, fish oil pills cost more per day than many councils spend on the entire school meal). That’s not my concern right here. What is interesting is where the attention of the media is drawn: weak and unpublished “scientific proof” for a miracle pill receives blanket coverage, while strong evidence for a parenting programme, from a rather prestigious academic journal, is deemed irrelevant.
Explanations abound. Firstly, of course, “pill solves complex social problem” feels more like a news story than a parenting programme does. And there is also the question of how stories are pushed: I’ve not met Hutchings et al, the authors of the parenting study, and if they want to persuade me, I’m perfectly prepared to believe that they are in Soho House until 2 am every night, schmoozing broadcast media journalists with champagne and nibbles, but in reality, I suspect they are modest academics.
Private companies, meanwhile, have top dollar public relations firepower, one single issue to promote, time to foster relationships with interested journalists, and a wily understanding of the desires of the public and the media. It is these wider cultural desires that are the key to exploiting our collective hopes and consumer dreams. Pharmaceutical companies have worked hard, let’s remember, in their direct to consumer advertisements and their lobbying, to push the serotonin hypothesis for depression, even though the scientific evidence for this theory is growing thinner every quarter, and the nutrition supplements industry, for its part, promotes dietary deficiencies as a treatable cause for low mood.
These crude biomedical mechanisms may well enhance the placebo benefits from medication. But I wonder if we also risk disempowering patients, and robbing ourselves of a deeper understanding, when we reframe complex social problems in such mechanistic terms.
The biomedical explanations may be so seductive precisely because of what they edit out. In the media coverage around the launch of pills for “female sexual dysfunction,” it wasn’t just the tablets that were being sold: stories on couples with relationship problems focused on biomedical interventions, and more than that, on hormone tests, or esoteric imaging studies of clitoral blood flow. We don’t want to talk about her feeling tired from over work, or him being exhausted by a new baby, any more than we want to talk about social inequality, the disintegration of local communities, the breakdown of the family, the impact of employment uncertainty, changing expectations and notions of personhood, or any of the other complex, difficult factors that play into the apparent rise of antisocial behaviour and depression.
In the past, medicalisation has been portrayed as something that doctors inflict on an unsuspecting world, and as an expansion of the medical empire: but in reality, biomedical narratives can appeal to us all, because complex problems have depressingly complex causes, and the solutions are often taxing and unsatisfactory. Given the choice, I’d have a miracle pill story, any day.