Medical–industrial complex

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Medical equipment and devices

The medical–industrial complex (MIC) refers to a network of interactions between pharmaceutical corporations, health care personnel, and medical conglomerates to supply health care-related products and services for a profit.[1][2] The term is derived from the idea of the military–industrial complex.[3]

Following the MIC's conception in 1970, the term has undergone an evolution by critical theory scholars throughout the early 21st century—including but not limited to the fields of disability studies, Black studies, feminism, and queer studies—to describe forces of oppression against marginalized communities as they exist in the healthcare field.[4][5][6][7] Mia Mingus, a writer, educator, and disability justice advocate, is one of such notable scholars who created a visual of the MIC.[5] Prior to the conception of the "medical-industrial complex" term, themes related to the MIC were discussed in earlier American society, as shown through the work and philosophies of Rana A. Hogarth and Francis Galton.[8][9]

The medical–industrial complex is often discussed in the context of conflict of interest in the health care industry and is often regarded as a result of modernized healthcare and capitalism.[10] Discussions regarding the medical-industrial complex often include the United States healthcare system.[3] These discussions about the MIC propose that pharmaceutical and healthcare companies, including for-profit chain hospitals, may influence physicians through financial incentives.[11][1] Physicians may also face constraints from corporate regulations and potential conflicts of interest related to investments in medical device companies.[12][13][14] Although some large medical journals have been criticized for potentially biased publications, efforts have been made to maintain neutrality in medical literature.[15][1] Continuing medical education programs funded by pharmaceutical companies may also influence physician preferences.[16] Finally, patients may be affected by the MIC through the promotion of cosmetic surgery, drug price inflation, and physician bias.[11][1] The Food and Drug Administration has implemented laws to protect patients against the potential negative impacts of the medical-industrial complex in the United States.[17][18] These perspectives on the medical-industrial complex also apply to countries outside the United States, such as India and Brazil.[19][20][21][22]

Drawing from diverse theoretical frameworks and the collective efforts of historically marginalized communities, critics have proposed alternatives to the medical-industrial complex that aim to reimagine health as a holistic concept, challenge the medicalization of sickness, and integrate lived experiences into healthcare settings.[23][8][24][25][26][27][28][29]

Term

The concept of a "medical–industrial complex" was first advanced by Barbara and John Ehrenreich in the November 1969 issue of the Bulletin of the Health Policy Advisory Center in an article entitled "The Medical Industrial Complex" and in a subsequent book (with Health-PAC), The American Health Empire: Power, Profits, and Politics (Random House, 1970).[30] In the 1970s profit-seeking companies became significant stakeholders in the United States healthcare system.[31] It was further popularized in 1980 by Arnold S. Relman while he served as editor of The New England Journal of Medicine.[32] In a paper titled "The New Medical-Industrial Complex" Relman commented, "The past decade has seen the rise of another kind of private "industrial complex" with an equally great potential for influence on public policy — this time in health care..."[32]

The Medical Industrial Complex Within the United States

Healthcare corporations

Pharmaceutical companies and chain hospitals are key healthcare corporations within the Medical Industrial complex.

Influence of pharmaceutical companies

Packaged drugs ready for distribution.[33]

Pharmaceutical companies are a leading influence in the expansion of the Medical-Industrial Complex.[34] Generic pharmaceutical drugs, which have the same chemical properties as branded, profitable drugs, are often sold for a fraction of the cost of their counterparts.[35] For example, a 10 mg dose of asthma medication Singulair can cost up to $250 per month, whereas its generic counterpart Montelukast costs only ~$20 per month.[36] Despite the inflated prices of brand-name drugs, pharmaceutical companies often induce bias in health care professionals by disproportionately promoting brand-name drugs.[37] For example, research has shown that pharmaceutical companies promote branded drugs more, making physicians more likely to prescribe an expensive medicine over a generic alternative.[38]

In addition to drugs, Laboratory Tests are also influenced by pharmaceutical company's vested interests. Physicians are more likely to order unnecessary tests when they are advertised by familiar pharmaceutical companies.[39] Like branded drugs, many pharmaceutical companies set these tests at inflated prices to increase profit.[39]

Influence of chain hospitals

Chain hospitals, in collaboration with pharmaceutical companies, also lead to the escalation of health costs.[40] A chain hospital is a subsidiary of a hospital network that works under a for-profit goal of expanding healthcare and establishing hospitals across a country, most notably the United States.[41] These corporations set standards regarding care administration, regulation, and enforcement – often without implementing a proper code of medical ethics.[42] Chain hospitals and other healthcare conglomerates hold a monopoly over health care costs within their hospitals and respective subsidiaries.[43] Thus, they can inflate healthcare costs with the goal of increasing profit, or lowering hospital standards to cut corners where necessary.[40]

This cost inflation is exacerbated by the fact that health care organizations are increasingly managed by business staff who often focus on economic gain, rather than local medical practitioners whose focus is patient benefit.[44] Moreover, hospitals in one state can be monitored by systems elsewhere, which gives significantly less power to local healthcare professionals.[45]

Bias in education

The curriculum of medical students often incorporates readings from large medical journals, like the New England Journal of Medicine.[46] These peer-reviewed journals may present results that favor expensive drugs manufactured by healthcare corporations or pharmaceutical companies, as these same corporations help to fund the journal.[47] As such, these large journals can perpetuate bias in healthcare providers' medication preferences by presenting results that are inherently influenced by the motives of businesses.[48]

Continuing medical education

Further information: Continuing Medical Education

Beyond medical school education, continuing medical education for healthcare is also subject to biased curriculum that disproportionately promotes the interest of its funders.[49] To continue practicing as a board-certified physician, a physician must take continuing medical education courses. Such programs ensure that physicians are up-to-date with new medicines and treatment plans.[50] However, these continuing education courses are often sponsored by pharmaceutical companies and healthcare corporations that can instill bias in physicians' education via the material provided.[51] For example, if a course is sponsored by a medical device company, then the coursework and exams used often reference using the company's medical device.[52] In turn, when the course is completed, it is more likely that physicians will use that medical device when interacting with patients regardless of if that medical device is necessary in the patients treatment.[52][49]

There are entities that work to reduce bias in continuing medical education courses, including the Accreditation Council for Continuing Medical Education.[53] Other groups, like the Medical education agency, work to reduce the influence of pharmaceutical companies and hospital corporations in the continuing medical education process.[53]

Cosmetic Rhinoplasty Results

Consequences

The Medical-Industrial Complex poses unique difficulties for patients and physicians. Diseases like chronic illnesses can tie a patient further into the Medical-Industrial Complex for the rest of their life.[54] Likewise, a terminal illness can force a patient to accept their soon passing, but also deal with the consequences of the illness and how they must pay for it.[54]

For patients dealing with recent wide-spread diseases like COVID-19, treatment often comes with steep prices in Medicare and insurance. In recent 2020 health-care research, data has expressed how pandemics like COVID-19 have further tested the preparedness of the entire system's ability to combat a rapidly spreading virus.

Patient-level

A health professional offers a unique service to patients, since patients are oftentimes completely vulnerable to the guidance and wisdom of their healthcare provider. Likewise, a patient needs unique, reliable help, especially in situations where they are physically, emotionally, and oftentimes financially vulnerable.[54] Many healthcare corporations exploit this vulnerability and can often in-debt patients as a result.[55] For example, if a person is involved in a car accident and becomes unable to communicate, they are taken to the nearest hospital.[56] Thus, they cannot refuse nor accept medical treatment.[56] This is especially important as it involves the complex interaction between making a profit from a patient's suffering, but also physicians having to treat the patient as effectively as possible.[55] For patients who do not have access to reliable health insurance, this imposes expensive medical treatment that they must pay for.[56]

For patients with a chronic illness, diagnosis often means expensive medications for the rest of one's life. Chronic illnesses like depression may require medications until the disease is treated, whereas more severe chronic illnesses like cystic fibrosis require expensive medical and pharmaceutical treatments for one's entire life.[57][56] These diseases could be treated but their unique long-lasting nature means money can be generated from life-long treatments as opposed to an end-all treatment.[56]

Individuals in low-income households and racial minority groups have experienced most of the impact of the Medical Industrial Complex during the pandemic as over one third of Latino adults or low-income adults were uninsured at some point during 2020.[58] This led to racial disparities in COVID-19 deaths for African Americans. For example, African Americans accounted for a quarter of the deaths to COVID-19, while only making up 12% of the United States population.[59]

Physician-level

Physicians are subjective to the Medical-Industrial Complex and its manifestations. Throughout the 21st century plastic surgery has become more common, where people have surgeries performed to solve a cosmetic issue.[56] Cosmetic surgeries are often used to satisfy a certain beauty standard. An example of this is a rhinoplasty, which is oftentimes a purely cosmetic surgery that is not life-saving or necessary for increasing one's quality-of-life.[54] For-profit healthcare introduces the idea of nonessential healthcare that can oftentimes more problems than solved.[60] Likewise, performing excessive amounts of cosmetic surgeries can increase one's social standing, signifying that they have the means to afford expensive, luxurious surgeries that others cannot afford.[60] For-profit healthcare promotes non-essential healthcare services so that more profits can be created from healthy populations.[54]

The phrase "no margin, no mission" is often used to describe for-profit healthcare, where medical centers will adapt to corporate interests so they can stay in business.[54][61] For physicians, this can mean not treating uninsured patients, performing unnecessary procedures that generate profit, or supplying better care to patients that have better means of pay.[56] This also has great moral and ethical considerations for physicians who feel obligated to better care for well-insured patients as opposed to under-insured, vulnerable patients.[62]

Corporate entities also enact standards over compliance, rules, disclosures and regulations.[54] These rules disregard ethical and moral dilemmas that physicians often face, setting unattainable standards on situations that cannot be determined by a clause.[63] Not only this, insurance companies also enforce rules and regulations surrounding medical treatment and payout.[54] Physicians are often tied between healthcare corporations and insurance companies determining what they can and cannot do for a patient, whether it is necessary or not.[64]

Manufacturers of medical devices fund medical education programs and physicians and hospitals directly to adopt the use of their devices.[65] Many pharmaceutical and medical device companies are investor-based, meaning that if a device or drug receives FDA approval the physicians will be financially invested in its success or demise.[66][67] Thus, a physician who is financially involved in a product or service is more likely to promote or use the product, whether or not its efficacy is known.[61] This provides a complex conflict of interest for physicians and patients, who may not receive effective, safe treatment due to physician bias for one product over another.[67]

According to Paul Starr, author of The Social Transformation of American Medicine, physicians hold a unique position between patients and hospitals.[68] The MI Complex can increase efficiency in hospitals, where patients can enter and receive care at quicker rates.[69][68]

Physician practices took a huge hit during the 2020 pandemic with thousands of primary care practices being forced to cut staff members due to the drop in patient volumes. These trends were consistent across the United States and other countries, detailing the difficulties the Medical Industrial Complex pertains with preparation for a pandemic like COVID-19. This was further detailed at the height of the COVID-19 pandemic, when one in every ten healthcare workers lost their jobs.[70]

Laws and policies

Sketch of a Dalkon Shield IUD

As indicated in Mia Mingus' diagram above, the "Medical Industrial Complex" is intertwined with the effects of economic policy on the practice of medicine. The Dalkon Shield is an interesting example of the conflict between economic profit and patient well being:

The Dalkon Shield was an IUD introduced in the late 1970's and 1980's.[71] The manufacturers of the device claimed that their IUD was safer than other forms of birth control available, and none of their reports noted any safety issues.[71] However, the long-term effects of the Dalkon Shield were not well known, and the IUD ended up being both ineffective and dangerous, resulting in many women becoming pregnant and facing severe pregnancy complications.[72] Moreover, because the device promised pregnancy prevention, many fetuses with severe birth defects were born as mothers did not follow medically-advised precautions during their pregnancy.[71] When the device was discontinued after CDC and FDA investigations, the IUDs was still not recalled and continued to endanger women who had them.[72] As such, the Dalkon Shield remained a dangerous medical device available in the healthcare market.[71][72]

Over a decade since the invention of the Dalkon Shield, the Safe Medical Devices Act of 1990 was passed by the FDA as an amendment to the FDCA.[73] This act required medical device manufacturer to report any information about medical devices that could contribute to death, sickness, or injury. As such, healthcare professionals were required to report malfunctioning or unsafe medical equipment.[74]

Additionally, the Physician Payments Sunshine Act, created by the United States Department of Justice, declared that all contracts that medical device companies make with physicians must be made public.[75] As such, this act could prevent future physicians from promoting or overusing medical devices on patients to further personal interests over patient benefit.[75]

In other countries

Indian Medical Association Clinic

The healthcare system in the United States performs worse on health indicators compared to other major nations, despite the country's higher investment in healthcare.[76] This is reflected in lower ratings for life expectancy and satisfaction among U.S. citizens.[77] Some argue that these lower ratings are partly due to the fact that the United States does not provide universal health coverage, unlike many other nations.[78][77] Some major differences between the United States and other major countries include quality, access, efficiency, equity, and life expectancy.[77]

White Savior Industrial Complex (WSIC)

See also: White savior

Countries in the Global South do not always have the same amount and quality of resources as countries in the Global North.[79] Due to these disparities, scholars argue that the White Savior Industrial Complex (WSIC) has influenced healthcare systems on individual, interpersonal, structural, and global levels.[79] Coined by Teju Cole, the WSIC refers to the phenomenon where privileged white individuals seek personal fulfillment by trying to "liberate, rescue, or otherwise uplift underprivileged people of color."[79][80] According to this concept, people with a white savior mentality may believe they know what is best for other countries, although such individuals often end up causing more harm than good. One such example describes how a white American physician caused Ugandan medical staff to doubt their knowledge and ability in delivering a baby.[79] Another example recounts how a White male physician used his privilege to influence medical staff in India to subvert their traditional medical practices.[79] Scholars cite these anecdotes as examples of how widespread the WSIC has become.[79]

India

Some individuals claim that the medical-industrial complex also exists in India, where the Indian Medical Association lobbies for their interests in local and state politics.[81] Specifically, some doctors have accused the Indian Medical Association of engaging in unethical practices and obstructing the advancement of healthcare systems within the medical profession.[82] The Indian Medical Association has responded to these claims by stating that their critics exaggerate rare occasions of unethical practices.[82] Yet, some doctors have privately admitted to immoral actions and have stated that these practices are not limited to a few individual patients.[82] Ethics is a contentious topic both within and beyond the medical profession. Claims of unethical practices may stem from the stark contrast between healthcare systems ranging from tall, high-tech hospitals to dilapidated, dirty ones.[83] Some medical professionals and scholars suggest that stricter office guidelines may decrease unethical practices, but this could also raise the cost of healthcare for patients.[82]

Brazil

In Brazil, scholars refer to the medical-industrial complex as the "healthcare-industrial complex."[84] The healthcare-industrial complex also expands beyond Brazil, where internal infrastructure fails to meet medical demands, leaving patients unable to access necessary products and services.[84][85] Scholars argue that Brazil's medical history reflects poor distribution of social and economic medical policies, resulting in underdeveloped and underfunded healthcare sectors in poor communities.[86] The Program for Investment in the Health Industrial Complex, or PROCIS, funds medical research in Brazil to advance the country's global presence in pharmaceutical and medical industries.[87][86] According to the Brazilian Ministry of Health, PROCIS was formed with the goal of developing Brazil's internal healthcare structure and promoting research, development, and treatment.[88] Over 100 billion Brazilian reals have been devoted to supporting medical research efforts, development of the medical industry, and innovating existing medical products.[89] The PROCIS also established a margin of preference on healthcare products that are nationally funded and sourced.[90]

Cultural Criticisms

A group of scholars and activists offer critiques and alternative approaches to the medical-industrial complex.

Alternative approaches

Alternative approaches to the medical-industrial complex incorporate elements from different theoretical frameworks and practices, such as holism, environmentalism, reproductive justice, the disability rights movement, feminism, and other related concepts.[91][92] These alternative approaches stem from the collective efforts of historically marginalized activists facing structural violence, including Indigenous, Black, and migrant communities.[93] According to various scholars, these alternative approaches aim to reimagine health as a holistic concept that extends beyond the traditional focus of the medical-industrial complex to include the body, mind, and spirit.[91][92][94] Furthermore, these alternative approaches challenge the medicalization of illness and disease by highlighting how structural factors shape health, rather than just individual behaviors.[93][94][95][96] Alternative approaches to the medical-industrial complex also challenge the boundaries between patient and provider to encourage collaboration between the two and to center the lived experiences of individuals in the healing process.[91][92][94][96] Additionally, they highlight the importance of forming caring relationships within one’s community to establish a sense of solidarity among individuals as equal participants in the healing process.[91]

Another alternative approach to the MIC is mindfulness, which emphasizes how the resources and tools for healing exist within the self and not within the solutions offered by the medical-industrial complex.[97] Another distinct approach from the medical-industrial complex is alternative health, which incorporates elements of traditional medicine and focuses on addressing underlying factors of disease rather than merely treating symptoms.[98] Alternative health, as a new social movement, provides a space for individuals and communities with diverse lived experiences to actively participate in the healthcare system while emphasizing their humanity in the healing process.[99] Scholars Jonathan Metzl and Helena Hansen advocate for a new approach to medical education in the United States, termed structural competency, which entails clinicians' ability to comprehend and address social determinants of health during patient interactions.[100]

See also

References

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