Consideration of this case exposes the limitations of global health frameworks that implicitly posit rich countries as the only sites of knowledge production. Analysis of iThemba identifies the problems inherent in global north/south divides at the same time as it highlights what is at stake in who makes knowledge and where. It also provides a concrete example for consideration of the contexts and practices of postcolonial science, its constraints, and its promise.
Synthesizing Hope explores the many legacies that create conditions of possibility for South African drug discovery, especially the specific form of settler colonialism characterized by apartheid and resource extraction. Paying attention to the infrastructures and laboratory processes of drug discovery underscores the materiality of pharmaceuticals from the perspective of their makers, and tracing the intellectual and material infrastructures of South African drug discovery contributes new insights about larger social, political, and economic orders.
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Questioning the Bifurcations in Global Health Discourses
In October 2008 I was in my first semester on the faculty at Georgia Tech and keen to meet other scholars and activists in Atlanta with whom I might share interests. One afternoon, I took the bus to nearby Emory University to attend the "International Access to Medicines" panel of a human rights conference held at the School of Law. It was a decision that I made on a whim, but it would turn out to be a fateful one. That panel was where I first learned about the small South African pharmaceutical company that would become my field site: iThemba Pharmaceuticals.
The panel focused on access to medicines in poor countries. One of the speakers was an Emory chemistry professor, Dennis Liotta, a prominent drug discovery scientist. Liotta and his collaborators were the researchers who discovered the key components of second-generation antiretrovirals, the HIV/AIDS drugs used in rich countries today. To an auditorium filled with people overwhelmingly of the opinion that increasing access to drugs would require reform of intellectual property (IP) laws, Liotta described an intriguing alternative approach. With passion in his voice as he methodically laid out his argument, Liotta made a case that the problem was not IP per se, but who owned it. He argued that the fact that IP is overwhelmingly owned by those in rich countries makes access to its products unaffordable to those in poor ones. Liotta argued that if drugs were discovered in developing countries and if companies based in those countries owned the IP, the drugs would be affordable to the poor and would be relevant to their needs. Building on this premise, he described two ways that he was trying to make it possible for African scientists to discover innovative drugs.
He first outlined a conventional model of knowledge transfer in which he was involved: a postdoctoral program that brought South African scientists to Emory to be trained in drug discovery. Yet Liotta pointed out that if the training happened without regard to the South African economy, it would only exacerbate brain drain. The scientists' skills would be unemployable in their own country if there were no companies in South Africa that could hire drug discovery scientists. He then described an intriguing complementary approach, exemplified by another initiative in which he was involved: a company that he was in the process of launching, called iThemba Pharmaceuticals, which was going to do research on diseases of the poor in South Africa. The start-up would be set up as a for-profit company, but with lower labor costs than such a company would have in a place like the United States, and with a public mission that would tolerate the lower profit margins of treatments for diseases that disproportionately affect the world's poor. The company would be a way to build scientific knowledge capacity in Africa, mitigating brain drain while also, it was hoped, finding new drugs that would be affordable to the global poor and relevant to their needs. I was immediately intrigued by an element of this project that struck me as unique: it linked the availability of drugs with the capacity for scientific knowledge making while paying attention to place. And, as I will describe, place was simultaneously geographical, political, logistical, and imaginative.
iThemba was a small company on the outskirts of Johannesburg that opened its doors in 2009, a fresh start after an earlier Cape Town–based effort had foundered. It was cofounded by Liotta and other elite scientists to find new drugs for TB, HIV, and malaria. It received start-up funding from the South African government, which owned half of the company. iThemba's founding mission, "inexpensive therapy for infectious disease through innovative chemistry," was a distinctive one. To illuminate this distinctiveness, in this chapter I will contrast iThemba's approach with that of the three most prominent discourses of pharmaceuticals and the Global South: access to medicines; bioprospecting; and clinical trials. Putting iThemba into comparative relief with these disparate sets of discourses reveals a common element among them. All three have an implicit reliance on a problematic conceptual bifurcation between Global North and South. South Africa itself is in many ways betwixt and between Global North and South, and this small drug discovery company's mission helps to illuminate some of the limitations of pharmaceutical knowledge-making projects that take that global bifurcation for granted.
Placing Pharmaceutical Knowledge Making: Beyond Access-to-Medicines Campaigns
In Liotta's comments at the conference on human rights and the law, I was struck that iThemba's approach differed from most approaches to solving the urgent health needs of Africans, which all frame the lack of access to drugs in poor countries as a failure to meet the needs of the Other. These initiatives are widely known as access-to-medicines campaigns, using the terminology of the campaign spearheaded by the nongovernmental organization Doctors without Borders, which aims to both increase access to existing drugs in poor countries and address the lack of investment in research and development directed toward treatments for the world's poor. Here, I will describe ways in which wide-ranging access-to-medicines campaigns — whether they promote distribution of generic drugs or incentivize researchers in the Global North to focus on diseases of the poor or attempt to do both — perpetuate global divisions in access to knowledge and power. Global health discourse recapitulates a troubling colonial legacy when "it configure[s] through language 'others' who would be the objects of research and the recipients of redistribution." Access-to-medicines campaigns can reinforce a bifurcation of the world between (1) knowledge creators who have a moral duty to create and share knowledge and (2) those in desperate need.
This geographic bifurcation between places of knowledge production and places where the only question is access is pervasive. For example, Universities Allied for Essential Medicines emphasizes the moral emergency of the lack of access to existing drugs and lack of research into diseases of the world's poor. Their solutions center on North American and European research universities sharing the fruits of their pharmaceutical knowledge with the Global South. Their motto — "our drugs, our labs, our responsibility" — is at once compelling and peculiar. The "our" locates but also circumscribes, implying that the only place that knowledge can be produced, and the only place that responsibility can be located, is in the Global North. The slogan reinforces the Global North's ownership claim to scientific knowledge at the same time that it advocates widening the scope of that knowledge's beneficiaries.
Social movements around generics as a solution to global health often exemplify taking the North/South bifurcation for granted, explicitly arguing for a framework in which intellectual property would be protected in rich countries but not in poor ones, so that Big Pharma could earn its profits in the former while the latter would be allowed to share the benefit. Many of these initiatives build on the legacy of the Treatment Action Campaign (TAC), an important South African social movement that was highly active and visible during the late 1990s and early 2000s and that successfully won access to generic antiretrovirals imported from other developing countries in the face of opposition from global pharmaceutical companies. This social movement victory was a powerful "globalization from below" that won access to the fruits of scientific knowledge. But as TAC fought against the "dissident science" of HIV denialism that was prevalent among South African leaders at the time — in which prominent government officials all the way up to President Thabo Mbeki cited marginal scientists' skepticism that HIV was the cause of AIDS as a reason for skepticism about the efficacy of antiretrovirals — TAC organizers had good reason not to advocate the democratization of knowledge production itself. The embrace of the importation of generic antiretrovirals as the solution to AIDS was a "strategic reductionism." TAC's emphasis on access over research was well founded: generic drugs can often be practical solutions for addressing immediate health needs of the poor. However, these symbolic politics have contributed to giving generic drugs a virtuous sheen in global health discourse, which is misleading because they are products of for-profit companies that are constitutive of, rather than outside, global property regimes. One cannot deny the real value of the drugs that companies in India and a handful of other countries supply, but this system is not the same as global democratic openness.
Generic production is itself a regulatory framework. In the global pharmaceutical production system of which generics are part, the legal ability to make particular drugs without a patent does not mean that anyone can make those drugs. As anthropologist Cori Hayden has argued, while generics provide a "counter-model to the expansion of exclusive property rights," they also create constitutive limits of "the proper copy." Unbranded drugs are not the same thing as unregulated drugs, and generic producers have a stake in robust regulatory processes that allow them to play the role of trusted producers. Generic-pharmaceutical companies are important but noninnocent actors in the access-to-medicines space. Generic-pharmaceutical companies might ally with civil society activism and indeed are often vital partners for patient movements because they are well positioned to be affordable providers of the essential drugs that patient movements demand. However, generic producers can also co-opt patient activism, manipulating that political will to their own commercial ends.
The framing of Indian generic-pharmaceutical manufacturers as acting in the service of the developing world might itself be understood as a successful example of generic manufacturers "unbranding" but then "rebranding" drugs — rebranding the products of profit-driven Indian generic industries as virtuous charity. This rebranding draws on a sentimentalized dream of Afro-Asian solidarity in ways that obscure ongoing hierarchies rooted in colonialism that situate dependent Africans "both below Indians in civilizational terms and behind them in temporal terms." Indian generic companies are symbolically and materially linked with charity, both because of their virtuous sheen and because they are the overwhelming providers of pharmaceuticals distributed by aid programs. However, charity does not always carry a positive valence from the perspective of its recipients. This is true both materially and symbolically: Indian companies disproportionately send inferior-quality drugs to Africa, and like pharmaceutical consumers elsewhere, South Africans often perceive free and generic drugs as less effective.
There is arguably considerable innovation involved in the reverse engineering done by these generic-pharmaceutical companies. However, even the reverse-engineering form of innovation turns out to be geographically limited, dominated by just a handful of countries (especially India and China but also Brazil and a few others). South Africa now has many generic-pharmaceutical companies, but these companies are materially dependent on global trade — especially with India — because they do not have the capacity to make the active pharmaceutical ingredients locally. These key components of the drugs must be imported in order for the South African companies to formulate, package, and distribute the finished drugs, and this in turn leads to considerable vulnerability to the supply chain. The generics sector is now highly competitive and low margin, and it is very hard for new companies in new geographic areas to enter. Even while iThemba explored business models that included generic manufacturing, its central mission was to discover innovative drugs for which it could own the patents.
At the same time, there are inherent limitations to what generic-pharmaceutical companies can provide. Relying on generic production of first world drugs means that the developing world can get only copies rather than novel drugs and thus that the needs of the poor will not set the priorities for novel-drug discovery. This positions the global poor in a way that excludes them as potential beneficiaries of cutting-edge innovation.
Generic drugs cannot fully escape their symbolic associations with the second-rate, and that matters for how they are positioned as panaceas for the poor. When technologies are designed and made specifically for the world's poor — as in the case of humanitarian technologies — they are generally made for what Peter Redfield (following Fiona Terry) has called the "second-best world." In this logic, it is taken as a given that the poor cannot have the ideal things, and alternative low-cost things are devised to make do. Paul Farmer's Haitian interlocutor was far more direct: "Do you know what 'appropriate technology' means? It means good things for rich people and shit for the poor." Old drugs might not necessarily be lower tech than new drugs, but the same logic applies. The assumption that the first world's side projects and leftovers are good enough for the rest of the world is a problematic one.
A key difference between iThemba and the movements around generics that I have discussed so far is the emphasis on research. In addition to "inexpensive therapy" and "infectious disease," there is an additional i phrase in iThemba's mission statement: "through innovative chemistry." The goal is not just to subsidize or lower the cost of existing drugs but also to discover new ones. In this sense, iThemba's efforts are aligned with those of the Gates Foundation, whose philanthropy supports both drug distribution and drug discovery.
The Gates Foundation's drug discovery work has overwhelmingly been channeled through product development partnerships (PDPs), a now-dominant global health drug discovery model that combines "philanthropic and state funds to support and subsidize drug discovery and development efforts, typically by commissioning research from pharmaceutical companies and academic institutions in Europe, Australia, and North America." These mechanisms are of a piece with the broader financialization of global health, in which philanthropic and state funds are seen as investments not only in health broadly but in intellectual and material products with a potential for return on investment.
iThemba participated in these PDP initiatives in a small way, albeit not as a "partner" but as a contract research organization. Contract research organizations that work in later-stage drug development, carrying out clinical trials for pharmaceutical companies in a fee-for-service model, are prominently discussed in the anthropology of pharmaceuticals in the Global South. Such organizations in the earlier-stage drug discovery space are less widely analyzed. These early-stage contract research organizations are chemistry-based companies that synthesize or analyze particular molecules for a fee. iThemba did this type of contract research as a way to earn money to sustain itself and support its in-house drug discovery initiatives. Its contract research clients included some of the most prominent PDP efforts, including the Doctors without Borders–initiated Drugs for Neglected Diseases Initiative and the Gates Foundation–dominated Medicines for Malaria Venture. Yet contract research does not really count as partnership: contract research organizations carry out much of the work of these projects, but they are rarely considered partners, because they simply provide service for a fee and do not participate in setting the research agenda. Thus, they maintain rather than trouble global hierarchies.
iThemba's peripheral status in these PDP efforts signals a deeper important element of difference. Gates and others have paid scant attention to who is making the science, and his organization's funding has preserved the Global North as the privileged location for innovative knowledge making. Even as they occasionally brandish photographs of African scientists (albeit much more rarely than they brandish photographs of African patients), his and other philanthropists' preference for funding scientists with "track records" provides a tremendous advantage to scientists in the Global North, and the Gates Foundation has prominently partnered with big pharmaceutical companies for neglected-disease research.
In the system of global flows that Gates has participated in creating, geography is central to organizing technological products: the system is designed such that cheap drugs and cheap computers flow to the Global South without disrupting high prices in the Global North. But the geography of technological innovators has little role in Gates's model. The research could conceivably be done anywhere, and it's easier and less risky to simply keep it where it is. From the Gates Foundation's perspective, present trends in where funded researchers are located might as well continue.(Continues…)
Excerpted from "Synthesizing Hope"
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Table of ContentsIntroduction / Hope in South African Drug Discovery
One / Questioning the Bifurcations in Global Health Discourses
Two / In the Shadows of the Dynamite Factory
Three / Science for a Post-apartheid South Africa
Four / “African Solutions for African Problems”
Five / Im/materiality of Pharmaceutical Knowledge Making
Six / Hope in Flow
Epilogue / The Afterlives of Hope