Catherine Will

The Alchemy of Clinical Trials

This article considers the complex construction of randomized controlled trials that lies behind the rhetoric of the gold standard. Drawing on insights from Science and Technology Studies and empirical material, I argue that trials in the field of cardiovascular disease prevention are constituted as ‘research’ rather than ‘science’. In these examples, control emerges out of a dual concern with practices of purification and involvement of aspects of the world outside the experiment, as the designers of trials aspire to relevance as well as rigour. Such strategies of ‘contextualization’ mean that trials are more like alchemy than assay, proceeding by complex moves to transform ‘base’ matters rather than distilling elements of clinical practice.

Genetic unexceptionalism: Clinician accounts of genetic testing for familial hypercholesterolaemia

This paper considers the implications of genetic testing in the case of familial hypercholesterolaemia, drawing on twenty semi-structured interviews with general practitioners (family doctors in primary care), nurses and specialists in hospital clinics (secondary care) in the UK. Though these professionals appear aware of and interested in the genetic component of the condition, and DNA testing is underway in at least some centres, their accounts suggest that the genetic test is not having a major impact on clinical work. Instead we find that professionals report that they generally rely on other information when making a diagnosis, especially cholesterol levels understood as a key risk factor, while the results of DNA tests, if used, come late in a much longer series of clinical investigations, judgements and interventions. In addition to elaborating professional views of genetic testing, the research provides a way of understanding other studies that describe lay people as not necessarily privileging genetic explanations of familial hypercholesterolaemia.

‘Prevention is better than cure, but …’: Preventive medication as a risk to ordinariness?

Preventive health remains at the forefront of public health concerns; recent initiatives, such as the NHS health check, may lead to recommendations for medication in response to the identification of ‘at risk’ individuals. Little is known about lay views of preventive medication. This paper uses the case of aspirin as a prophylactic against heart disease to explore views among people invited to screening for a trial investigating the efficacy of such an approach. Qualitative interviews (N = 46) and focus groups (N = 5, participants 31) revealed dilemmas about preventive medication in the form of clashes between norms: first, in general terms, assumptions about the benefit of prevention were complicated by dislike of medication; second, the individual duty to engage in prevention was complicated by the need not to be over involved with ones own health; third, thepotential appeal of this alternative approach to health promotion was complicated by unease about the implications of encouraging irresponsible behaviour among others. Though respondents made different decisions about using the drug, they reported very similar ways of trying to resolve these conflicts,drawing upon concepts of necessity and legitimisation and the special ordinariness of the particular drug.

Mutual Benefit, Added Value?

The National Health Service (NHS) has recently been the focus of government efforts to retain pharmaceutical research in the UK. Efforts to foster new partnerships between healthcare providers and industry have been framed with suggestions that clinical trials can offer ‘patient benefit’ within the NHS, cutting across ethical and sociological concerns with the possible tension between doing research and offering care. This paper draws on ethnographic research to explore the sometimes awkward juxtapositions between trial protocols and everyday care, individual health and commercial profit, and thus the distribution of value produced through trials. While researchers appear to find the distinction between research and care useful, at least some of the time, both formal and informal strategies for living with this distinction may have the unintended consequence of making research appear supplementary to rather than simply different from clinical care.

On difference and doubt as tools for critical engagement with public health

Abstract This paper argues that critical public health should reengage with public health as practice by drawing on versions of Science and Technology Studies (STS) that ‘de-centre the human’ and by seeking alternative forms of critique to work inspired by Foucault. Based on close reading of work by Annemarie Mol, John Law, Vicky Singleton and others, I demonstrate that these authors pursue a conversation with Foucault but suggest new approaches to studying contemporary public health work in different settings. Proposing that we ‘doubt’ both the unity of public health and its effects, I argue that this version of STS opens up a space to recognise multiplicity; to avoid idealising what is being criticised; and to celebrate or care for public health practices as part of critique. Finally I oppose the view that considering technologies, materials and microbes leads to micro-level analysis or political neutrality, and suggest that it allows us to reframe studies of public health to account for inequalities and to draw attention to weak or retreating states, active markets and the entangled relations of humans and non-humans across the world.

Identifying Effectiveness in ‘‘The Old Old’’ Principles and Values in the Age of Clinical Trials

This article explores some implications of the increasing reliance on clinical trials in contemporary health care, particularly health care payers’ efforts to use them in the so-called fourth hurdle decisions. How do these agencies manage medical uncertainty given the desire to produce clear guidelines for clinicians? Their solutions take account of trials in at least two ways, reflecting broader debates about the meaning of these medical experiments. Trials can be read as either ‘‘proofs of protocol’’—straightforward guides to action with individual drugs in specific populations—or ‘‘proofs of principle’’— where extrapolation is made possible through an appeal to underlying biological mechanisms. These contrasting readings of trials are illustrated with reference to guidelines on heart disease prevention/cholesterol reduction using statins among the elderly in North America and the United Kingdom. Uncertainty in these cases does not lead to inertia but solutions use different fixed points to aid navigation, including both physiological principles and moral values.

Materiality matters: Blurred boundaries and the domestication of functional foods

Previous scholarship on novel foods, including functional foods, has suggested that they are difficult to categorise for both regulators and users. It is argued that they blur the boundary between ‘food’ and ‘drug’ and that uncertainties about the products create ‘experimental’ or ‘restless’ approaches to consumption. We investigate these uncertainties drawing on data about the use of functional foods containing phytosterols, which are licensed for sale in the EU for people wishing to reduce their cholesterol. We start from an interest in the products as material objects and their incorporation into everyday practices. We consider the scripts encoded in the physical form of the products through their regulation, production and packaging and find that these scripts shape but do not determine their use. The domestication of phytosterols involves bundling the products together with other objects (pills, supplements, foodstuffs). Considering their incorporation into different systems of objects offers new understandings of the products as foods or drugs. In their accounts of their practices, consumers appear to be relatively untroubled by uncertainties about the character of the products. We conclude that attending to materials and practices offers a productive way to open up and interrogate the idea of categorical uncertainties surrounding new food products.

Do-it-yourself heart health? 'Lay' practices and products for disease prevention

Abstract This paper considers how ‘health behaviours’ are imagined and practised in contemporary society, considering the combination of commercial products such as over the counter (OTC) statins and functional foods with more established ‘healthy behaviours’ in everyday life. Using data from users of low dose statins licensed for OTC sale in the UK and functional foods, we consider policy fears that such products would dilute efforts at healthy living. In line with sociological literature, we encountered resistance to pill-taking and accounts of health behaviour that show this to be a complex category that may involve functional or mundane foods, and supplements, may be highly targeted at heart health, or more defuse goals, or involve a degree of vagueness as to what is being used and why. Thinking about these practices as a form of ‘DIY’ provides a useful supplement to sociological interest in lay rationality, drawing attention to the objects rather than knowledges enrolled, and the provisional nature of health practices.

The management of enthusiasm: motives and expectations in cardiovascular medicine.

Debates about appropriate action in medicine often turn on finding the right emotional orientation to new developments. In this article enthusiasm emerges as a key term in a professional ‘vocabulary of motive’ around innovation, complicating current sociological interest in expectations. The negative associations that adhere to this word among clinical researchers indicate awareness with the difficulty of managing hype and public hopes, but analysis of its use by cardiologists over the past two decades also reveals tension around more specific professional dangers, including ‘credulity’ and inappropriate activism. An emphasis on clinical trials offers one resolution, but additional narrative strategies can be identified when discussing when to start such trials here illustrated for stem cells for cardiac repair. In particular, while some suggest delaying trials until there is good knowledge of mechanism gained in the laboratory, others support early clinical research through gestures of therapeutic and epistemic modesty.

Constituting practices, shaping markets: remaking healthy living through commercial promotion of blood pressure monitors and scales

ABSTRACT Commercial actors play a key role in promoting public health agendas as they move into space previously occupied by the state-sponsored health sector and welfare state. This paper examines how marketing of digital self-monitoring devices promotes public health. Existing self-monitoring research often separates or compares positions of commercial actors and users, using a discourse lens to examine commercial actors’ ‘expectations’ and ‘promises’, and user research focusing on ‘practices’. The research on which this paper is based moves beyond this divide, examining commercial and user worlds through a practice lens. We draw on the research’s first stage which examined self-monitoring device marketing, arguing that marketing can be understood as constituting self-monitoring practices. Much literature on self-monitoring focuses on novel networked devices, resulting in potential over-emphasis on change and innovation. Taking cases of well-established bodily monitoring (weighing and blood pressure), we set self-monitoring within a longer history. We draw on Shove’s practice theory which attends to histories of practices and evolutions in practices required elements materials, meanings and competences. Commercial companies are shown to rework well-embedded practices as they constitute the practice elements of self-monitoring. They thus keep in play continuities and novelty, maintaining connections to health while moving away from clinical associations. We argue that, in constituting self-monitoring practices as ‘aesthetic’, ‘enjoyable’, and ‘shared’, commercial actors address implicit resistances to negative connotations of ‘individualised’, ‘responsibilised’ consumer citizens implied in neo-liberal health-promotion agendas, widening the self-monitoring market and promoting public health by creating more desirable ‘lifestyle’ practices.