Written for ANTHRCUL 327: Medicine and Healing, taught by Professor Liz Roberts in Fall 2017
The expansion of biomedical technologies in recent years has introduced an array of faceless organizations and systems that increasingly tighten their grip on the lives of individuals through rules, regulations, and policies. These powers include pharmaceutical and insurance companies, medical practitioners, and governmental bodies. Individuals have begun to rely on biomedical products to maintain their own lifestyles and comfort, and thus, the distributers of these technologies have begun to exert a sort of “invisible control” over their lives. This phenomenon is clearly displayed in the article Amid Opioid Crisis, Insurers Restrict Pricey, Less Addictive Painkillers by Katie Thomas and Charles Ornstein: insurers have limited patients’ access to safer opioid treatment options in favor of cheaper drugs which often are stronger and more addictive. This policy has negatively impacted the lives of several individuals, including Alisa Erkes, a 28-year-old Georgian woman who suffers from severe abdomen pain. She was previously treated with Butrans, a safer and less addictive opioid, but due to insurance policy changes, she was forced to switch to morphine, which carries a stronger risk of addiction (Thomas and Ornstein 2017, 2). The control that insurers and pharmaceutical companies have over Erkes’ life can be examined from the lens of Foucault’s idea of “biopower”, described in Right of Death and Power over Life as working to “incite, reinforce, control, monitor, optimize, and organize the forces under it: a power bent on generating forces, making them grow, and ordering them” (Foucault 1978, 136). Additionally, this particular case of biopower in relation to the opioid crisis in the United States can be related to Helena Hansen and Mary E. Skinner’s examination of social stigmas associated with different opioid addiction treatment medications in From White Bullets to Black Markets and Greened Medicine: The Neuroeconomics and Neuroracial Politics of Opioid Pharmaceuticals, and to Phillipe Bourgois’ study of the methadone clinic and how its structure profoundly affects individual lives in Disciplining Addictions: The Bio-Politics of Methadone and Heroin in the United States.
Foucault’s interpretation of Alisa Erkes’ situation and the situation of opioid treatment access as a whole might focus on the role of the insurers as reinforcing biopower over the lives of patients. In describing the transition from sovereign power (where concrete entities overtly exert power over a population) to biopower, he states “[o]ne might say that the ancient right to take life or let live was replaced by a power to foster life or disallow it to the point of death” (Foucault 1978, 139). In Erkes’ case, her life is not disallowed to the point of death, but it is heavily inconvenienced and her quality of life plummets resulting from the biopower being exerted on her through these insurance policies. After being denied Butrans, Erkes “who once visited the doctor every two months, was now in Tate’s office much more frequently, and once went to the emergency room because she could not control her pain” (Thomas and Ornstein 2017, 6). Her life is controlled at a biological level due to her need to take Butrans to function properly, and because of this dependence, she is influenced heavily by the insurance policies that allow or disallow her to obtain Butrans over a drug like morphine, which is much stronger, less effective, and more addictive. In addition to noting the clear influence of biopower on Erkes’ life, Foucault would question why the system to treat pain provides greater access to stronger opioids like morphine over non-opioids like Lyrica. Thomas and Ornstein’s article explains that cost is a major factor. The reason why UnitedHealthcare, Erkes’ insurer, stopped providing Butrans to its patients was because of the high price of the drug (Thomas and Ornstein 2017, 2). From Foucualt’s perspective, there could also be a secondary reason embedded in the universal nature of biopower itself. Foucault states that within biopower, people often cite a ““right” to life, to one’s body, to health, to happiness, to the satisfaction of needs, and beyond all the oppressions or “alienations”, the right to rediscover what one is and all that one can be” (Foucault 1978, 145). Through seeking this “right to life”, Erkes’ becomes even more embedded into the system of biopower because in order to obtain health, she is forced into an insurance system which exerts almost complete control over her everyday comfort. She is also more heavily “monitored” by the biomedical system due to her more frequent hospital visits and need to be checked for addiction. In addition to being cheaper, providing low-cost opioids such as morphine to patients might make them more easily monitored. The amount of control that Erkes’ insurers hold over her life serves as an example of biopower at work, and the division between different types of drugs based on cost can also reveal larger socioeconomic trends.
In Helena Hansen and Mary E. Skinner’s article From White Bullets to Black Markets and Greened Medicine: The Neuroeconomics and Neuroracial Politics of Opioid Pharmaceuticals, it is described that different opioid maintenance treatments are associated with different social classes, contributing to increased class distinctions and reinforcing racial stigmas against Latinos and African Americans living in low-income areas. This stratification can be seen in Thomas’s article on a more general level. Patients are being put on stronger opioids such as morphine, instead of less addictive medication, due a variety of factors barring them from receiving proper addiction treatment. In Hansen and Skinner’s article, they mention a variety of economic factors contributing to the prevalence of certain drugs over others, specifically citing the case of buprenorphine being marketed as a white, middle-class drug being prescribed in a “clean clinical atmosphere removed from poverty, ethnic minorities, and street crime” (Hansen and Skinner 2012, 171). This is presented in juxtaposition to methadone, which was commonly used to treat addiction in inner city public health clinics and came to be associated with Blacks, Latinos, and other low-income minorities. In the case of Thomas’ article, Erkes is denied access to Buprens, which contains buprenorphine, due to its high cost compared to morphine. Although morphine is more addictive and less effective for her condition, she is forced to use it because of financial reasons (Thomas and Ornstein 2017, 2). Essentially, a neuroeconomic system is making her more dependent on drugs. Upon reading Thomas’ article, Hansen and Skinner might find some nuance because of Alisa Erkes as a white female being barred from using buprenorphine, which is commonly associated with white racial categories. However, the article overall highlights Hansen and Skinner’s argument that different amounts of access to certain drugs increase class stratification.
In Disciplining Addictions: The Bio-Politics of Methadone and Heroin in the United States, Phillippe Bourgois highlights the effect of methadone clinics on the “specific intellectual” (Bourgois 2000). Bourgois’ work heavily relates to Thomas and Ornstein’s article because of its emphasis on individual experiences in the wake of biopower. Additionally, Bourgois tries to apply some of Foucault’s aforementioned concepts in a practical way, which can provide a framework for how the concept of biopower might be applied to the case of Alisa Erkes’ and others mentioned in the Thomas and Ornstein piece. Methadone is an opioid utilized in the United States in public clinics treating heroin addicts. Various individuals are entrenched in the methadone clinic system, and their everyday lives are dictated by when they must visit the clinic for the dose, whether they can receive a dose, and what dosage they should receive. Primo, a methadone addict in New York City, experiences his addiction as a system of social control and dependency, and suffers changes in his family life and work habits due to it. The clinic continuously raises his dosage because of his “slipping” and shooting heroin, which further alienates him from his family because of methadone’s negative side effects on his body. Bourgois states that “The political economic contraints limiting Primo’s life chances (i.e. unemployment, felony record, medical bills, housing market, etc.) are already overwhelming, and methadone’s rigid institutional regulations further curtail his options for autonomous change” (Bourgois 2000, 172). This is similar to Alisa Erkes’ situation since her everyday life is also dictated by various powers deciding when she needs to receive treatment and what kind of treatment she receives. She is first given Butrans, which seems to manage her pain well, but her insurer forces her to switch to extended-release morphine, which is possibly addictive (Thomas and Ornstein 2017, 2). In both cases, the individuals themselves have little to no control over their treatment, and overbearing entities such as methadone clinics, national laws, and insurance companies seem to dictate the outcome of their lives. Bourgois would relate this to the idea of the power/knowledge nexus formed by Foucault: the biomedical practitioners and those involved with the treatment process are given authority over the patients themselves because of their knowledge of biomedicine, despite the patient having a unique individual body. The knowledge that the biomedical practitioners possess allows them to exert power over people who do not have this knowledge (Bourgois 2000, 183).
The issue of insurance companies being unwilling to cover weaker and less-addictive painkilling treatments is related to the larger discourse of biopower due to the amount of control these insurers hold over individual lives. Analyzing the situation from the point of view of Foucault’s work can nuance the situation by considering secondary reasons for cheaper opioids being more accessible than other treatments, since with treatment under these opioids, patients will need to be more closely monitored for addiction. Additionally, Hansen and Skinner’s piece analyzes the issue from a socioeconomic point of view and considers the social and racial stigmas associated with using certain drugs over others. Finally, Bourgois’ study of methadone clinics in the United States provides additional views of specific individuals trapped in a system of biopower that they cannot escape. Biopower permeates throughout the lives of these individuals, and while there is not a clear solution to how to solve the issues created from the regulation of the medications they depend on, perhaps the anthropological discourse on biopower will cause some biomedical practitioners to consider the power they can exert over individual lives and the amount of autonomy they are allowing their patients.
Bourgois, Philippe. 2000. “Disciplining Addictions: The Bio-Politics of Methadone and Heroin in the United States.” Culture, Medicine, and Psychiatry. 24: 165–195.
Foucault, Michel. 1978. “Right of Death and Power Over Life.” The History of Sexuality Vol. 1.
Hansen, Helena and Mary E. Skinner. 2012. “From White Bullets to Black Markets and Greened Medicine: The Neuroeconomics and Neuroracial Politics of Opioid Pharmaceuticals.” Annals of Anthropological Practice. 36(1): 167–182.
Thomas, Katie and Charles Ornstein. 2017. “Amid Opioid Crisis, Insurers Restrict Pricey, Less Addictive Painkillers.” ProPublica.