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Global Pharmaceuticals

Duke University Press

Chapter One

ADRIANA PETRYNA AND ARTHUR KLEINMAN

Worldwide, images of well-being and health are increasingly associated with access to pharmaceuticals. Media advertisements invite arthritis sufferers to celebrate with co-sufferers who have become pain free after consuming the latest blockbuster anti-inflammatory drug. A playful bouncing ball asks us if we suffer from malaise and hopelessness as it transforms into a lock-and-key chemical-based model of depression. Given the magic of such self-transforming images, it is not surprising that marketing and advertising had their beginnings in the pharmaceutical industry. Images of magical make-over represent a multi-billion-dollar-a-year commerce that promises innovative drugs to wipe out disease and alleviate suffering in the world. In their attempt to achieve universal reach, however, these marketing efforts and images traverse vastly different worlds with vastly uneven social and economic conditions.

Juxtapose these images with other images, such as those of the massive crisis of global AIDS and multi-drug-resistant tuberculosis-crises that threaten national securities and require complex forms of intervention. Over 60 million people have been infected with HIV, and morethan 25 million have died since the beginning of the epidemic. In some African countries, one in four adults is HIV-positive and five million people are newly infected each year. Diminishing access to public health services and treatment, and political instability around the globe have increased the flow of pathogens and the likelihood of resistance, and have made infection hypermutable. While infectious diseases that primarily affect poor societies remain undertreated, global markets for antidepressant and antipsychotic treatments have grown. Numbers tell a story. In 2002, global sales of antidepressants grew by 5 percent and sales of antipsychotics rose by an astonishing 19 percent. Among the leading therapy classes in global pharmaceutical sales, antidepressants rank fourth and antipsychotics rank fifth.

The modern pharmaceutical industry got its start in the nineteenth century when several potent compounds-including alkaloids such as morphine, strychnine, quinine, nicotine, and cocaine-were isolated and mass produced. Major pharmaceutical breakthroughs occurred during and after World War II, including the discovery of penicillin (and methods to mass produce it), streptomycin to treat tuberculosis, and the first broad-spectrum antibiotic, chloramphenicol. Corticosteroids, tetracyclines, oral contraceptives, antihistamines, tranquilizers, amphetamines, diuretics, and hundreds of other medicinal compounds were patented in the late 1940s and early 1950s. Even before World War II, the pharmaceutical companies operated internationally by relying on licensing and marketing agreements, subsidiaries, and joint ventures. After the war, the industry used sophisticated marketing methods to transform from a commodity chemicals business (with individual pharmacists compounding the dose) to one heavily concentrated in several large firms and dependent on large investments in research and marketing. Global pharmaceutical spending reached almost $500 billion in 2003; approximately half of that was attributed to the United States and Canada. In 2003, the top ten drug companies enjoyed a profit of 14.3 percent of their annual sales (compared with a 4.6 percent median for other industries; see Angell 2004:11).

Behind these figures lies a morass of economic and moral paradoxes. Some therapeutic markets are launched (for example, antidepressant sales have risen sharply among low-income groups) while other no less urgently needed markets are ignored. The alarmingly slow development of the anti-HIV drug market in Africa has been attributed to the allegedly unreliable medical and economic behaviors of that continent's desperately poor HIV sufferers. These characteristics are said to heighten investment risk, which traditionally justified the industry's failure to make low-cost drugs accessible to those who need them. Inertia also exacts a high cost: misguided policy and insufficient private incentives often keep in place the wrong types of intervention. For example, the ongoing use of ineffective treatments for malaria is causing a dramatic rise in malaria-related deaths. Tropical diseases in poor countries do not present the same kind of economic incentives that drive the proliferation of chronic disease treatments in rich countries. Witness the relative abundance of lifestyle treatments versus the scarcity of treatments for disorders uncommon in the West. Industry discourse reinforces this gap in value as it sponsors cures for diseases that have a proven consumer base, or extends the limits of treatable illness to enlarge markets for new products (Lexchin 2001; Moynihan, Heath, Henry 2002). Thus, at least two distinct pharmaceutical markets have evolved based on group behavior, culture, or economic characteristics and their potential to enhance industry profits.

Advertisements present us with distinctive, and highly disputable, imagery that supports this consumption-oriented logic. Well-being is recast as a commodity and as a distinct personal achievement. Side by side with depictions of individualized health are images of more collective forms of suffering that are portrayed as inchoate or hopelessly untreatable. These images convey distinct moralities, suggesting that illnesses can be valued and treated differently (Kleinman and Kleinman 1996). As moral economy becomes based on political economy, possibilities are foreclosed and violence is perpetrated when populations and communities are treated in drastically unequal ways. Lifestyle is fostered pharmaceutically for some while benign neglect is the order of the day for others. New major initiatives such as the Global Fund, private foundations, and public-private partnerships for drug research and development have evolved to promote investment in health research and technology transfer for diseases and countries that are deemed unprofitable investments for research and development. The continued existence of separate spheres of risk raises questions about the anthropological dimensions of new pharmaceuticals and about the innovative empirical work that is required to convey the moral and ethical realities of emergent global drug markets.

The coexistence of effective life-extending technologies and lost life chances in local places where essential medications remain unavailable presents contemporary ethnography with an urgent challenge to make sense of this paradox-to plumb its technical, political, and social depths. Anthropological studies have significantly advanced our understanding of the relationship between income inequalities and health (Chen et al. 1994; Desjarlais et al. 1995; Kim et al. 2000; Farmer 2003), showing how health inequities build on socioeconomic and political divisions within and between countries and among racial and ethnic minority groups. They have shown, for example, how differences in the structure and organization of institutions authorized to deal with health problems (state bureaucracies, welfare agencies, insurance companies, medical facilities, and religious/humanitarian organizations) result in distinct programs and policies that not only differ greatly in form and content but also can create different courses of health and disease and influence their outcomes of both. Other authors have removed the air of obviousness with which the concept of culture is deployed to explain local health practices. In refuting the notion that the poor are somehow less responsible regarding treatment regimes, they have exposed how cultural assumptions in health planning can further entrench inequality, justifying some interventions while disallowing others (Farmer 1999).

This body of anthropological work has shown how the local trajectories of pandemics are influenced by international policy and choices (Das 1999). There is little doubt that a failure to respond adequately to the aids pandemic has contributed to an exponential growth of infection in South Africa-from 0.7 to 20.1 percent in the adult population between 1990 and 2001. Other patterns of delay have been found in regions in political transition. In Eastern Europe in the early 1990s, for example, rapidly opening markets combined with economic shock therapy threatened the lives of vast numbers of people as social services were being reduced. The reality of these threats was counter-balanced by the euphoria accompanying the advent of social and political freedoms and the promises of democratic governance. The World Bank and the International Monetary Fund (the two international agencies most influential in advising developing countries) focused resources on institutional reforms rather than on health. Pharmaceuticals needed to fight AIDS and tuberculosis were distributed too late, and the delay produced a new set of local health concerns. Anthropologists have pointed to the inadequacies of ethical discourse for assessing health equity and health rights in politically and economically devastated communities because it does not have a way to account for local moral worlds as social processes (Kleinman 1998). They have argued for a lifting of the ban on moral engagement with worlds that are unjust, chaotic, and riddled with violence and premature death (Scheper-Hughes 1992; Bourgois 1995; Das et al. 2000; Biehl 2005).

This volume's ethnographies complement these studies and bring new perspectives-anthropological and cross-cultural-to bear on the issues posed by the growth of the international pharmaceutical trade. The essays gathered here grew out of the Third Annual W. H. R. Rivers Workshop held at Harvard University in May 2002. The workshop assembled leading anthropologists working in the field of science and medicine and historians of medicine-scholars who in their own areas of research are concerned with the human consequences of pharmaceutical use and their market expansions in cross-cultural and everyday contexts. The combined viewpoints of the authors acts as a prism, breaking these issues into their component parts and providing a multilayered look at the interests and stakes involved in the production of pharmaceuticals and their consumption in particular times and places. They undertake at least two levels of analysis. On the one hand, the authors examine the cultural, scientific, and economic practices that contribute to the growth of the drug industry; and on the other hand, they investigate how this expansion, as well as the proliferation of treatments, affects various forms of inequality and health practice. Many extend the anthropological technique of the close analysis of such practice to broader structuring agencies-governmental, nongovernmental, corporate, professional-whose decisions affect the well-being of populations. The essays in this volume examine the proliferating global institutional ecology of pharmaceuticals created by intense competition for regional markets and a tug-of-war between pharmaceutical importation in poorer countries and the evolution of drug production capabilities in medium-poor countries like China, India, and Brazil. Elements in this new ecology include the World Bank, the World Trade Organization, and trips, and a host of emerging international and national regulation and law, which set the terms for pharmaceuticals' worldwide and regional circulation. This institutional ecology moves within and across more traditional, territorially bounded apparatuses of governance. Analyses of medical professions, advertising agencies, audit companies, and contract research organizations also highlight the recurrent theme of territoriality in these essays: how social and institutional geographies of healthcare are remapped and how physician practices and patient agency are remade.

These fine-grained studies of the global movements of pharmaceuticals also reveal an emerging "values gap." Its symptoms include the growing division between populations that have access to life-saving drugs and the ability to pay for them, and populations that have neither and must rely on some other form of distribution. The gap is intensified by the choices made by industry: afflictions whose treatments are relatively easily produced and have ready markets are deemed more worthy of research and development. It is also reinforced by the subtle and not so subtle ways by which the significance of others' well-being is judged. Human experiences of suffering and its costs can have little bearing on economic measures of costs of "morbidity" and other indicators configuring social need (Kleinman and Kleinman 1996). In other instances it is economic worth-specifically, market readiness (or lack of it)-that can determine the fate of whole populations. Arguably, this is a most critically important issue presented by the flow of pharmaceuticals: Whose illness is worth treating? Whose life is worth saving? Jim Kim, an anthropologist and physician who is the former director of the World Health Organization's HIV/AIDS Department, questions why, given empirical data showing that it is possible to save the lives of the desperately poor, these men, women, and children are routinely cut off from needed medical treatments. A key source of this paradox, he claims, is a pervasive "public health machismo," the idea that "someone has to make the decision as to who lives and who dies" at the highest levels of international health planning. What is new about the globalization of pharmaceuticals is the dramatic degree to which action, resources, and coordination are required and can be mobilized to counteract the extreme and debilitating effects of pharmaceutical triage. Debates over access to new medical technologies must consider complex care delivery systems for the poor; and the role of state and non-state actors in securing "health" as a fundamental good and right of citizenship has never been more profound.

The question of the social good and to whom it applies filters through every phase of pharmaceutical production, from preclinical research to human testing, marketing, distribution, prescription, and consumption. Each step is marked by a "particular context, actors, and transactions and is characterized by different sets of values and ideas" (Van der Geest et al. 1996:153). Each phase entails specific ethical concerns and problems. Decisions about what therapeutic entity to develop are connected to institutional priorities that may have little to do with the realities of disease and treatment demand. A telling example is provided by Anne Lovell's discussion of heroin addiction in France and the current lack of antiaddiction pharmaceuticals. The market potentiality of drug compounds is more typically defined by country than by need. And as Adriana Petryna notes in her essay, the settings in which new drugs are clinically tested may be entirely different from the settings in which they are sold. Which populations should researchers include in their research cohorts? Sometimes public pressure and interest group activists can accelerate the development of innovative drugs, as in the case of antiretrovirals (Epstein 1996) and cancer therapeutics (Lowy 2000). This form of research activism is taken as standard policy today, as access to experimental therapies is being broadened and drug trials are increasingly viewed as therapeutic rather than experimental commodities (especially for populations historically underrepresented in clinical research, such as women, children, the elderly, and members of racial and ethnic minorities).

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