Health, Risk & Society

ISSN: 1369-8575 (Print) 1469-8331 (Online) Journal homepage: http://www.tandfonline.com/loi/chrs20

Drugs, risk and society: Government, governance

or governmentality?
Andy Alaszewski
To cite this article: Andy Alaszewski (2011) Drugs, risk and society: Government, governance or
governmentality?, Health, Risk & Society, 13:5, 389-396, DOI: 10.1080/13698575.2011.601579
To link to this article: http://dx.doi.org/10.1080/13698575.2011.601579

Published online: 05 Aug 2011.

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Health, Risk & Society

Vol. 13, No. 5, August 2011, 389396

EDITORIAL
Drugs, risk and society: Government, governance or governmentality?

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Andy Alaszewski*
Centre for Health Services Studies, University of Kent, Canterbury, UK

This themed issue of Health, Risk & Society on Drugs, Risk and Society brings
together six articles reecting the importance of drugs in the study of health risks.
The articles fall into three groups. The articles by Davis and Abraham (2011) and
Gardner and Dew (2011) explore the government of risk and the ways in which
regulators use scientic expertise to identify and control risks. Both articles show
the limitations of such expertise and the inuence of other processes. Davis and
Abraham (2011) examine the ways in which political pressure on the US Federal
and Drug Administration has made it more sympathetic to pharmaceutical
companies. Gardner and Dew (2011) analyse the ways in which regulators in
New Zealand were forced to respond to patient and media claims that a new
formulation of Eltroxin caused side eects even though there was no scientic
evidence for such claims. The second group of articles (Himmelstein et al. 2011,
Jin et al. 2011) explore the governance of drugs and the ways in which
governments seek to inuence drug use through public health measures. This
approach involves the sharing of the responsibility for the management of the
potentially harmful eects of drugs with experts providing potential users with
information on these eects and encouraging rational and the responsible use of
drugs. Both articles show that this approach is likely to have limited eects if it
does not address the underlying reasons for drug misuse, in the case of Chinese
villages the pressure on local doctors to prescribe and sell antibiotics to their
patients to maintain their incomes (Jin et al. 2011), or there is a lack of awareness
or trust of the source of information, as is the case of parents in the UK and US
buying over-the-counter cough and cold medicines for their young children
(Himmelstein et al. 2011). If governments and their agents disregard individual
understanding and perceptions they can be seen as using risk to construct social
problems; those threatening the established order of society. The papers in the
nal section of this issue consider ways in which individual drug users resist such
control and develop their own assessment of risk and their own patterns of drug
use. Harrison and her colleagues (2011) consider the Australian government
eorts to control the consumption of alcohol, in order to minimise its harmful
eects and in particular to reduce young peoples harmful binge drinking habits.
The participants in this study saw themselves as engaging in controlled
drunkenness. These young people were interested in the pleasurable not the
harmful aspects of alcohol consumption. In terms of the public health guidelines,
most of these young people were binge drinking however they saw their drinking
as reasonable and safe. McGovern and McGovern (2011) examine crack
cocaine: an illegal heavy-end drug which drug regulators consider causes
considerable harm to its users and others and wish to prohibit. However for the
crack cocaine users it was a purposeful activity. It enabled users to create

*Email: a.m.alaszewski@kent.ac.uk
ISSN 1369-8575 print/ISSN 1469-8331 online
2011 Taylor & Francis
DOI: 10.1080/13698575.2011.601579
http://www.informaworld.com

390

A. Alaszewski
meaning in otherwise meaningless lives. Crack cocaine enabled individuals to
develop and demonstrate specialist and valued skills and knowledge and
negotiate the dangerous edge inherent in heavy-end crack cocaine use and
control the uncontrollable.
Keywords: risk; drugs; government; governance or governmentality

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Introduction
This issue of Health, Risk & Society on Drugs, Risk and Society groups together a
number of papers independently submitted to the journal. This themed issue reects
the importance of drugs in the study of health risks. This interest was evident
in earlier volumes of the journal. In the special issue on globalisation (Volume 3.1)
Yi-Mak and Harrison (2001) explored the ways in which eighteenth and nineteenth
century imperialists deliberately encouraged the consumption of opium in China to
balance Imperial trade and the ways in which such policies underpinned more recent
patterns of consumptions of illicit drugs. This broad approach to the political and
cultural contexts of drug use is unusual; most of the articles published in Health,
Risk & Society on drugs and risk have focussed either on the ways in which
governments try to regulate and manage the risks associated with drugs or on the
ways in which individuals perceive the risks associated with drugs and how this
inuences patterns of use. The articles in this issue reect and build on these themes:
the rst two articles explore the government of risk and the regulation of drug
production; the second two articles explore the governance of drugs and the ways in
which governments seek to share the responsibility for the management of the
potentially harmful eects of drugs by sharing information about these eects and
encouraging responsible use of drugs; and two papers in the nal section explore
governmentality and drugs and in particular the ways in which users resist and reject
government attempts to shape their behaviour to ensure the safe and responsible use
of drugs.
The government of drug risk: The nature of regulatory regimes and their response to
evidence of the harmful eects of drugs
In late modern societies legal drugs are created and manufactured by pharmaceutical companies . . . [who] have real commercial interests in making prots from the
drug products they (seek to) market (Abraham 2002, p. 319) and are consumed by
individuals who have real health interests in both minimising the toxic risks and
maximising the therapeutic ecacy of the drug products made available to them
(Abraham 2002, p. 319). Given the asymmetry in access to information on risks and
the ways in which drug side eects may have major impact on some individuals, it is
very dicult for individuals to opt out of these risks. As Hood and his colleagues
(1999) note, in such circumstances it is rational for the government to intervene in
the market through regulation. Such regulation is usually designed to balance the
benets of supporting the development of protable and innovative pharmaceutical
companies with protecting the public from the potential harmful eects of
consuming drugs.
The Thalidomide disaster of the late 1950s indicated the limitations of selfregulation by pharmaceutical companies, and governments in industrial democracies
have taken on the responsibility for regulating pharmaceutical products; approving

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or licensing the use of new drugs and withdrawing or limiting the use of existing
drugs as and when evidence emerges of particularly harmful side eects. Such
regulation is usually delegated to an agency which uses technical and scientic
expertise to assess the evidence derived from the trials undertaken by the
pharmaceutical company seeking to market a new drug or, in the case of existing
drugs, from post-approval surveillance. As Davis and Abraham (2011) note in their
article in this issue, in the case of the United States of America this regulation is
undertaken by the Food and Drug Administration, while in Europe drug regulation
is undertaken by the European Medicines Evaluation Agency and its expert
Committee for Proprietary Medicinal Produces.
The regulatory system is designed to maintain public trust in the safety of drugs
by using independent scientic expertise to assess the benets and hazards of drugs.
However Davis and Abraham (2011) argue that there is evidence of risk
colonization, particularly in the USA where powerful industry interests have
combined to produce permissive, rather than precautionary, risk management within
pharmaceutical regulation. This represents a major change as in the 1970s and 1980s
regulation in individual European states such as the United Kingdom was light
touch while the FDA had a relatively confrontational relationship with
pharmaceutical companies. Davis and Abraham (2011) argue that the FDA has
been subject to political pressure especially from neo-liberals committed to
minimising state intervention. In contrast in Europe the regulators are expert
scientists seconded from individual nations who are insulated from political pressure
and less vulnerable to pressure to minimise regulation.
Davis and Abraham (2011) show that in recent periods the US Food and Drug
Administration avoided withdrawing approval for drugs when potentially fatal side
eects emerged by risk managing: communicating information on these side eects
to potential users of the drugs. As Osimani (2010) has pointed out communicating or
sharing information about hazards with potential users of drugs is a major way of
managing uncertainty enabling producers to transfer the responsibility for decision
making and risk taking to the users. Davis and Abraham (2011) argue that the FDA
approach was not successful as risk communication did not result in the safer use of
the dugs involved, and the drugs involved had to be removed from the market.
Since the regulatory systems that Davis and Abraham (2011) are analysing are
operating in large complex settings, they are unable to explore the minutiae of drug
regulation and decision making. In contrast Gardner and Dew (2011) examine the
case of Eltroxin, a medicine used to treat hypothyroidism, in New Zealand. In the
relative small-scale and open context of New Zealand the underlying decisionmaking process comes into clearer focus and the process is inuenced by claims
making (see Alaszewski and Brown 2012) in which the regulators eectively
disregarded expert evidence and opinion.
Gardner and Dew (2011) describe how in 2007 a new formulation of Eltroxin
was introduced in New Zealand and within a year there were reports of non-fatal
side eects such as joint and muscle pains, depression and visual disturbances. The
government drug regulation agency, Medsafe, and the committee responsible for
monitoring adverse drug eects, Medicines Adverse Reaction Committee, both
investigated and found no evidence of a medical or physiological basis for the
reported side eects. The drug manufactures and drug regulators argued that there
should be no dierence between the new and previous formulation of Eltroxin as the
active ingredients were the same. However claims by patients suering from

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hypothyroidism that the new formulation was causing unpleasant side eects and
was therefore unsafe received wide-spread media coverage enabling patients both to
share their experience and to report their side eects directly to the Centre for
Adverse Reactions Monitoring. The issue was then taken up by politicians. In
response to media coverage and politicians concerns, regulators in New Zealand
decided to approve and make Goldshield, a drug manufactured in the UK, available
to patients suering from hypothyroidism in addition to Eltroxin.
These articles analyse the ways in which the expert rationally-oriented drug
regulatory systems are structured by and inuenced by their political and social
contexts. In Davis and Abraham (2011), political pressure on drug regulators in the
USA has resulted in regulation which is more sympathetic to drug company interests
and a greater willingness to shift responsibility for managing serious drug side eects
from producers to users through risk communication. In contrast in New Zealand
the proximity of drug regulators to the drug users, the media and politicians has
made them more receptive to claims that Eltroxin caused side eects and oer an
alternative even where there was no scientic evidence to support the claim.
The governance of drug risks: Communicating and sharing risks
As we have argued in the previous section, governments in industrial democracies
have taken on the responsibility for regulating pharmaceutical products, and these
regulatory systems reect their political and social contexts. In industrial
democracies, systems of regulation have changed in line with changes in the
structure and nature of governments. In the United Kingdom the cosy club culture
of the mid-twentieth century with either light-touch or self-regulation with close
relations between policy makers and producers has been replaced with more formal
relations with structured regulation with some user representation (Moran 2003).
This change can be seen as a shift from government to governance with elitist top
down decision making being complemented by broader participatory processes. The
shift to governance can be seen as part of the neo-liberal programme of shrinking
Big Government by enabling citizens to take over state activities. For example, in
the Davis and Abraham (2011) analysis of the Food and Drug Administration,
communication of the risks of serious side eects can be characterised as shifting
some of the cost and responsibility of risk and risk management to citizens.
The shift to governance can also be seen as recognition of the limitations of
government power and the ability of government to inuence or control harmful
activities or behaviours. This is particularly pertinent in relationship to drugs. While
much drug use is benecial, there are also uses which are collectively harmful which
the government would like control. In the eld of drugs the shift from a paternal
relationship to one based more on partnership can be seen at individual or patient
level in a shift of rhetoric from patient compliance with drug regimens to
concordance (Bissell et al. 2004, p. 852).
The two articles in the second section of this issue examine two examples of such
use and the factors which limit government impact on the potentially harmful use of
drugs. The article by Jin et al. (2011) focuses on an area of drug misuse that causes
considerable concern; the excess prescription and use of antibiotics contributing to
the development of drug resistant diseases. They focused on four villages in China;
examining the factors contributing to the misuse of antibiotics, for example their
intravenous delivery to treat common colds.

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Paradoxically Jin et al. found considerable concordance between the villagers

and their doctors. The villagers, especially those coming from poorer families,
felt they knew very little about drugs and relied completely on local doctors who
they trusted to provide them with information about drugs and treat them. This
trust was grounded in a number of factors; villagers had developed relationships
with their local practitioners when they were barefoot doctors under the premarket communist system, and had condence in (expensive) western scientic
medicine. Indeed their condence in scientic medicine was so high that they
expected it to develop new drugs to deal with diseases that have developed
resistance to existing drugs. The villagers trust in their local doctors was to some
extent misplaced. Following the market reforms of health care in China, exbarefoot doctors could no longer rely on government funding and had to develop
new sources of income; particularly selling expensive drugs to villagers.
Unscrupulous ex-barefoot doctors (and other providers) abused villagers trust to
over-prescribe antibiotics.
Himmelstein et al. (2011) consider the ways in which parents in the UK and
USA respond to drug regulators concerns about the purchase and use of overthe-counter cough and cold medicines for young children. Both the USAs Food
and Drug Administration and the UKs Medicines and Healthcare Products
Regulatory Agency have issued guidelines discouraging parents from using such
medicines with children under six years old. Himmelstein et al. (2011) found that
despite the eorts of regulators to communicate their concerns about the risks of
such drugs to young children the message was not getting through to parents and
when it did get through most parents were unwilling to act on it. For example in
the UK there was widespread media coverage of the MHRA recommendations
but one third of the parents in Himmelstein and her colleagues sample were
unaware of the MHRAs concerns about use of over-the-counter cough and cold
medicines for young children. Furthermore half of the participants who did know
about the MHRA concerns and the recommendation that they should not give
such drugs to their children did not believe the drugs were potentially harmful or
were not sure what to believe. These parents showed a lack of trust in the
regulatory body. There was a similar lack of trust amongst American parents.
Himmelstein et al. (2011) argue that drug regulatory bodies in both the UK and
USA need to build public trust and improve the communication of risk information.
However there may be an intrinsic aw in this approach to the management of drug
risks. Governance can be seen as a more sophisticated way of managing the
potentially harmful eects of drugs than the traditional government approach. The
governance approach seeks to develop partnership through the communication of
relevant information. However as the articles in the second section of this themed
issue make clear, this approach will also fail if it is not grounded in realities of drug
production, marketing and use. If the government agencies seek to impose their
denitions of risk and prescribe how drugs should be safely used without regard to
those of drug users then their intervention can be seen as a form of governmentality
or social control.
Governmentality and drug risks: Resistance and rebellion
Governmentality can be seen as the construction and use of knowledge to manage
behaviours that challenge the established order of society. It involves a broad shift

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in forms of surveillance and control from those based upon direct, face-to-face
relationships between experts and subjects to those based upon the abstract
calculation of risk (Petersen 1997, pp. 189204). The papers in the nal section of
this issue consider ways in which individual drug users resist such control and
develop their own assessment of risk and their own patterns of drug use.
Harrison et al. (2011) consider the Australian government eorts to control the
consumption of another drug, alcohol, in order to minimise its harmful eects and
in particular to reduce young peoples harmful binge drinking habits. The
National Health and Medical Research Council argued that binge drinking is likely
to adversely aect the development of the brain before it is fully developed at 25
years. Governments do not consider that alcohol has a therapeutic or medicinal
eect but in most countries adults can legally buy and consume alcohol, and its
(moderate) consumption is generally considered to be pleasurable. Harrison et al.
(2011) identify the public health strategy proposed by the Australian government
in draft guidelines produced. These are based on the concordance model and
provide information on the risks of drinking to persuade individuals to minimise
harm to themselves and others through low-risk drinking: a maximum of two
standard drinks per day.
Harrison et al. (2011) argue that such strategies are limited and unlikely to
achieve the desired eect. In particular they note that these strategies dene young
people in a particular way; ascribing particular rationality, choices and risks to
young people. They argue that such strategies seek to engineer in young people
forms of personhood that are characterised by similar understandings of the risks
they face, and choices that they should make, in relation to their uses and
consumption of alcohol. The young people in the study by Harrison et al. saw the
risks they faced and the choices they made in relationship to the consumption of
alcohol in a dierent way. In particular they saw the consumption of alcohol as
pleasurable and socially desirable. The participants in this study saw themselves as
engaging in controlled drunkenness. For all of the young people in the study,
alcohol provided a sense of condence. They used alcohol to improve their mood
and sociability while maintaining self-control. In terms of the public health
guidelines, most of these young people were binge drinking however they saw their
drinking as reasonable and safe.
McGovern and McGovern (2011) examine use of crack cocaine; an illegal heavyend drug which drug regulators consider causes considerable harm and wish to
prohibit. Public health experts tend to focus on the individual and collective harm of
heavy-end drug use, treating it as an addiction and seek to provide the knowledge
and treatment which users need to kick the habit. As Harrison et al. noted, in
relationship to binge drinking, regulators do not consider the perceived benets of
drug taking such as the pleasure of drug taking or the sense of self which users can
derive from drug taking.
In their article, McGovern and McGovern (2011) provide an alternative account
of heavy-end drug use derived from the accounts by drug users of their crack cocaine
use. They use Lyngs (1990) analysis of voluntary risk taking as edgework in which
individuals experience excitement and develop their sense of themselves by
challenging themselves through undertaking dangerous activities such as mountain
climbing. Viewed from this perspective, using crack cocaine is a purposeful activity.
It enabled users to create meaning in otherwise meaningless lives. Heavy-end crack
cocaine use enabled individuals to develop and demonstrate specialist and valued

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skills and knowledge and negotiate the dangerous edge inherent in heavy-end crack
cocaine use and control the uncontrollable.
Final comment: Government, governance or governmentality?
The development and use of drugs is an important feature of late modern society.
The development of science and technology has enabled legal and illegal producers
to create and manufacture an extensive array of substances that aect the bodies and
minds of individuals living in these societies. While most of the eects are highly
benecial, there are also harmful eects from the side eects of some drugs and the
misuse of others. It seems reasonable that the government in these societies should
seek to control the production, marketing and consumption of drugs so as to
maximise their benets and minimise the harm they can cause. Such regulation is
presented as rational, being based on expert evaluation of scientic evidence about
the benets and risks of specic drugs. Actual analysis of regulatory decisions
indicate that they are open to other inuences: in the case of the US Food and Drug
Administration, pressure from neoliberal politicians has made regulators more
sensitive to the interests of pharmaceutical companies and more willing to transfer
risk to users through risk communication; while in New Zealand, regulators were
responsive to users claims that the new formulation of Eltroxin caused side eects
although there was no scientic evidence to support these claims.
While governments seek to control the risks associated with the production of
drugs through regulation, controlling consumption requires a more subtle
approach and is generally done through public health measures: the communication of risks of using specic drugs and advice on safe use. The success of the
public health approach depends on the eectiveness of the communication, the
extent to which potential users trust the source of information and advice and
the extent to which those targeting the advice understand the perceptions and
motivations of those using the drugs. The articles in the second and third part of
this issue indicate limitations in all three areas but particularly in tailoring
information and advice to potential users perceptions and motivations. The
assumption that users will accept that drug use can be harmful and will rationally
wish to reduce the levels of harms to which they are exposed does not take into
account the benets that users perceive, for example the pleasures of binge
drinking or of using crack cocaine.

References
Abraham, J., 2002. A social science framework for the analysis of health technology
regulation: The risks and benets of innovative pharmaceuticals in a comparative context.
Health, Risk & Society, 4 (3), 305324.
Alaszewski, A. and Brown, P., 2012. Making health policy: A critical introduction. Cambridge:
Polity Press. In Press.
Bissell, P., May, C.R., and Noyce, P.R., 2004. From compliance to concordance: Barriers to
accomplishing a re-framed model of health care interactions. Social science & medicine, 58
(4), 851862.
Davis, C. and Abraham, J., 2011. A comparative analysis of risk management strategies in
European Union and United States pharmaceutical regulation. Health, Risk & Society, 13
(5), this issue.
Gardner, J. and Dew, K., 2011. The Eltroxin controversy: Risk and how actors construct their
world. Health, Risk & Society, 13 (5), this issue.

Downloaded by [b-on: Biblioteca do conhecimento online UBI] at 11:57 16 January 2016

396

A. Alaszewski

Harrison, L., et al., 2011. I dont know anyone that has two drinks a day: Young people,
alcohol and the government of pleasure. Health, Risk & Society, 13 (5), this issue.
Himmelstein, M., et al., 2011. Over-the-counter cough and cold medicines for children: A
comparison of UK and US parents parental usage, perception and trust in governmental
health organisation. Health, Risk & Society, 13 (5), this issue.
Hood, C., et al., 1999. Explaining risk regulation regimes: Exploring the minimal feasible
response hypothesis. Health, Risk & Society, 1 (2), 151166.
Jin, C., et al., 2011. Framing a global health risk from the bottom-up: User perceptions and
practices around antibiotics in four villages in China. Health, Risk & Society, 13 (5), this
issue.
Lyng, S., 1990. Edgework: A social psychological analysis of voluntary risk taking. American
Journal of Sociology, 95 (4), 851886.
McGovern, R. and McGovern, W., 2011. Voluntary risk-taking and heavy-end crack cocaine
use: An edgework perspective. Health, Risk & Society, 13 (5), this issue.
Moran, M., 2003. The British regulatory state: High modernism and hyper-innovation. Oxford:
Oxford University Press.
Osimani, B., 2010. Pharmaceutical risk communication: Sources of uncertainty and legal tools
of uncertainty management. Health, Risk & Society, 12 (5), 453469.
Petersen, A., 1997. Risk, governance and the new public health. In: A. Petersen and
R. Bunton, eds. Foucault, health and medicine. London: Routledge, 189204.
Yi-Mak, K. and Harrison, L., 2001. Globalisation, cultural change and the modern drug
epidemics: The case of Hong Kong. Health, Risk & Society, 3 (1), 3957.