Format: Journal

Sarah Pinto explores the emergence of so-called ‘informal providers’ of medicine and biomedical care in rural India. These providers are neither ‘formal’ nor ‘informal’, she argues, but instead “operate on the boundaries of legitimacy” (340). These ‘informal providers’ often fill the gaps where legitimate public health institutions have been too weakened to operate, and are informally sanctioned by the state because their operations are not regulated or denounced. These informal providers, Pinto writes, are actually “neither ‘quacks’ nor legitimate doctors”, but typically lay people who have self-trained, or been partially trained via a development scheme. They can “invent roles for themselves as medical authorities and representatives of development” (337) by claiming the authority of development and medical institutions. These claims go uncontested by legitimate institutions, who are aware of their work filling the gaps in communities with severely limited access to good health care.

In policy and development debates about ‘informal providers’ and their clients, though, informal providers are often characterized as rogue actors, both ‘irrational’ and exploitative, and clients are portrayed as uneducated and easily fooled. On the other hand ‘formal’ institutions are understood as modern, cosmopolitan; decidedly rational actors and purveyors of legitimate biomedical knowledge. In this way, what Pinto explains, is that despite on the ground evidence to the otherwise, formal and informal get defined in opposition to each other. Informal providers are “those against whom the educated and rational self is defined” (2004:356). The danger here is that we fail to understand the reasons why informal providers are trusted in the everyday lives of those who seek health care in environments with limited formal options, and likewise the institutional reasons they are propped up by governments and development organisations.

In some parts of the world spending on pharmaceuticals is astronomical. In others people do not have access to basic or life-saving drugs. Individuals struggle to afford medications; whole populations are neglected, considered too poor to constitute profitable markets for the development and distribution of necessary drugs. The ethnographies brought together in this timely collection analyze both the dynamics of the burgeoning international pharmaceutical trade and the global inequalities that emerge from and are reinforced by market-driven medicine. They demonstrate that questions about who will be treated and who will not filter through every phase of pharmaceutical production, from preclinical research to human testing, marketing, distribution, prescription, and consumption.

Whether considering how American drug companies seek to create a market for antidepressants in Japan, how Brazil has created a model HIV/AIDS prevention and treatment program, or how the urban poor in Delhi understand and access healthcare, these essays illuminate the roles of corporations, governments, NGOs, and individuals in relation to global pharmaceuticals. Some essays show how individual and communal identities are affected by the marketing and availability of medications. Among these are an exploration of how the pharmaceutical industry shapes popular and expert understandings of mental illness in North America and Great Britain. There is also an examination of the agonizing choices facing Ugandan families trying to finance AIDS treatment. Several essays explore the inner workings of the emerging international pharmaceutical regime. One looks at the expanding quest for clinical research subjects; another at the entwining of science and business interests in the Argentine market for psychotropic medications. By bringing the moral calculations involved in the production and distribution of pharmaceuticals into stark relief, this collection charts urgent new territory for social scientific research.

The drug patent monopoly has been described as a key deterrent to Africans’ access to brand-name, life-saving drugs. Research in Nigeria, however, shows that another factor restricts access in that country: Brand-name pharmaceutical companies’ pricing and marketing strategies keep patented drugs off the market. In this article, I retheorize the question of monopoly in the pharmaceuticals industry. I first track the historical precedents of this particular iteration of the drug monopoly. I then situate the monopoly in the context of ethnographic research I conducted on pharmaceutical markets and drug marketing (2005–10) as well as on Nigeria’s compliance struggles with the WTO’s Trade Related Aspects of Intellectual Property (TRIPs) Agreement (1999–2003). TRIPs enforces patent holders’ rights and mandates intellectual property harmonization across nation-states. In analyzing these two ethnographic sites together, I argue that rather than its purported short-term legal existence, the current drug monopoly operates as though it has an indefinite life.