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The Pharmaceutical Journal
Vol 268 No 7194 p543
20 April 2002

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Anthropology can benefit pharmacy

By Malcolm Brown


The physician Osler (1849?1919) said: "The desire to take medicine is perhaps the greatest feature which distinguishes man from animals." This article examines that desire and connects it with prescribing and current issues such as compliance, doctor- and pharmacist-patient relationships and patient concerns.

The pharmacists Horne and Barber suggest that medical anthropological study could benefit pharmacy.1 My starting point is to observe that medicines are things; they possess a concrete presence, unlike, say, "talking" cures such as psychotherapy. The body is a biochemical machine; if it malfunctions, chemicals (drugs) can help to restore equilibrium. This perspective is second nature to pharmacists and doctors. Anthropologically, medicines are "thingified verbal signs".2 They have "itness"3 and the intrinsic power to heal. If the problem is physical, the remedy, also, is physical: a technical fix — a visible sign that the physician can heal.

Next, notice that medicines are portable. The professional's control over the patient continues through the physical presence of the medicine, even when the patient is alone at home (albeit less strongly).4

Professional control is absent when patients directly access medicines, for example, from garage forecourts. Such access is politically correct, being democratic. Anyone has power to access, although the Ritz principle applies: only those with sufficient money can access. For example, nicotine chewing gum 2mg is seen by some smokers as being too expensive. It is the empirical medicine that is desired. The doctor's bag, clinic or dispensary without medicine are oxymorons — like a bar without beer.

No matter where obtained, once the medicine is in the patient's possession, control by pharmacists and physicians is loosened, unlike the activity of the surgeon, which demands physical presence. Medicine can be ignored, taken incorrectly — or given to another person. Ibuprofen, given to an asthmatic or Daonil given to a non-diabetic could be unfortunate. Pharmacists and doctors attempt to reduce such risks by preaching that only the patient named on the medicine label should take that medicine.

Wearing anthropological spectacles, that observation about preaching suggests that prescribed medicines are more like fetishes than charms.5 A fetish is an anthropomorphised machine, activated by the designer or sorcerer, performing appropriate ceremonies and incantations over symbolic paraphernalia. Examples are the stage props of the British National Formulary, computer, prescription and medicine label, including boxes embellished by the initials of dispenser and checker. A charm possesses mystical power as an attribute of the thing itself. The prescribed medicine itself is supercharged with potency. That occurs especially when it contains knowledge so esoteric that it possesses a kind of mystery or tender loving care (TLC) from the healer: the personal touch that cannot be found in books. TLC need only be fleeting. Examples are a GP confessing about Lamisil, "It worked on my toenails", or the pharmacist demonstrating using three, 500ml bottles of Gaviscon, "The bag should hold it, but maybe you should hold the bag by the bottom — like this." Medicines contain deep symbolism; medicines, such as placebo or homoeopathic medicine, an example being aconite for stress, may work even if they contain no pharmacologically active ingredient.

Material proof

Initially, the prescription is the material proof that doctor, pharmacist and patient remain connected. Prescriptions are frequently stored as protectively as paper money; I have often observed prescriptions unfolded from purses. Then, the prescription is translated into the actual medicine — but it continues its connection with the doctor. The medicine remains a concrete presence bridging the gaps between doctor, pharmacist and patient. The patient's confidence in treatment is reawakened by the concreteness of the medicine, just as a seashell held to the ear, for one moment, summons the sound of the waves upon the beach. Then, (generally) the ingested medicine empirically works: a self-fulfilling prophecy that convinces the patient, more firmly, that the prescriber was a good doctor and so, in turn, that the trust placed in that prescriber was justified. Similarly, medicine that works convinces the patient, more firmly, that the dispenser was a good pharmacist and so, in turn, that the trust placed in that pharmacist was justified.

Prescribers may be located within a spectrum of activity from promiscuity to parsimony. Whatever the extent of prescribing, the doctor is trying to do something, by offering chemical comfort.6 Occasionally, patients present symptoms to community pharmacists, only divulging care histories after 10 minutes. Those patients may have exhausted the advice from GPs and hospital consultants and have experienced batteries of tests. The pharmacist has become the "the physician of last resort" and, if able to offer anything, patients often seem appreciative. "You've done something. You've tried to help. That's the main thing", said one.

That observation about a pharmacist echoes published observation about (and by) a medical practitioner: "What makes the physician is not only what he knows, or what he does, or even how he does it — much of the time, just that he does it."7 In other words, the process is as important as the outcome.

All this provides useful insights into non-compliance. Patients seldom possess pharmacists' or physicians' detailed knowledge of Western biomedicine; however, patients do possess, in their own terms, sophisticated, logical models of disease and cure. The healing process includes going to see the physician, the prescription, the dispensing, and then having something to hold and to take away: the physic or medicine — a trophy that legitimates that patient's sick status.

However, actually ingesting that medicine, especially if anxious about the side effects publicised by the package insert, mass media or next-door neighbour, risks unpleasant consequences. Patients' may then decide not to take the medicine. But the benefit from the legitimating ritual may still occur. When the patient volunteers to a pharmacist, "I've got this prescription for Prozac but I don't know whether I want to take it," the pharmacist really will earn his or her bread during the next few challenging minutes.

I suggest that pharmacists attached to general practitioner surgeries are in a splendid position to share, with their GPs, a related insight and to suggest action. Specifically, GPs could, perhaps, modify patients' logic, and enhance compliance, by routinely looking each patient between the eyes and saying something like, "This medicine, like many others, has side effects but I always try never to give you anything which does more harm than good." Record that advice in the patient's notes (so that it is not repeated). For each patient, that advice could take about 10 seconds. It could be time well spent.


References

1. Horne R, Barber ND. Medical anthropology ? its significance for pharmacy Pharm J 1993;250:859.

2. Poulton J. F?tiches sans f?tichisme. Paris: Fran?ois Maspero; 1975. p119.

3. Van der Geest S, Reynolds Whyte S. The charm of medicines: metaphors and metonyms. Med Anthropol Quart 1989;3:361.

4. Brown ME. Pharmacists: emperors of entropy. Pharm J 2000;264:769.

5. Ellen R. Fetishism. Man 1988;23: 232.

6. Pellegrino ED. Prescribing and drug ingestion symbols and substances. Drug Int Clin Pharm 1976; 76:624.

7. Majno G. The healing hand man and wound in the ancient world. London: Harvard University Press; 1991. p68.


Malcolm Brown is a pharmaceutical consultant, locum pharmacist and sociologist

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