Development without Institutions

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.

Anthropological Perspectives on Structural Adjustment and Public Health

Thirty years since its first public use in 1980, the phrase structural adjustment remains obscure for many anthropologists and public health workers. However, structural adjustment programs (SAPs) are the practical tools used by international financial institutions (IFIs) such as the International Monetary Fund (IMF) and the World Bank to promote the market fundamentalism that constitutes the core of neoliberalism. A robust debate continues on the impact of SAPs on national economies and public health. But the stories that anthropologists tell from the field overwhelmingly speak to a new intensity of immiseration produced by adjustment programs that have undermined public sector services for the poor. This review provides a brief history of structural adjustment, and then presents anthropological analyses of adjustment and public health. The first section reviews studies of health services and the second section examines literature that assesses broader social determinants of health influenced by adjustment.

Global Pharmaceuticals

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.

On the monopoly

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.

What Can Critical Medical Anthropology Contribute to Global Health?

We are now facing an unprecedented moment in the history of global health, in which infectious diseases such as HIV/AIDS, malaria, and tuberculosis are no longer peripheral concerns but primary targets of bilateral aid programs, philanthropy, and research. The Critical Anthropology of Global Health Special Interest Group of the Society for Medical Anthropology is committed to bringing a critical perspective to global health that encompasses factors that contribute to the maldistribution of disease, health care inequities, and problems in health care management, within a biopolitical environment.

Post-Pasteurian Cultures

Out of concern for public health, the U.S. government bans the sale of cheese made from unpasteurized milk if it is aged fewer than 60 days. But while the FDA views raw-milk cheese as a potential biohazard, riddled with pathogenic microbes, aficionados see it as the reverse: as a traditional food processed for safety by the action of good microbes. This article offers a theoretical frame for understanding the recent rise in American artisan raw-milk cheese production, as well as wider debates over food localism, nutrition, and safety. Drawing on ethnographic interviews with cheese makers and purveyors and on participant-labor conducted on a Vermont sheep dairy farm, I develop the concept of microbiopolitics to analyze how farmer–cheese makers, industry consultants, retailers, and consumers negotiate Pasteurian (hygienic) and post-Pasteurian (probiotic) attitudes about the microbial agents at the heart of raw-milk cheese and controversies about this nature–culture hybrid.

Thick Prescriptions

Anthropologists of medicine and science are increasingly studying all aspects of pharmaceutical industry practices–from research and development to the marketing of prescription drugs. This article ethnographically explores one particular stage in the life cycle of pharmaceuticals: sales and marketing. Drawing on a range of sources-investigative journalism, medical ethics, and autoethnography–the author examines the day-to-day activities of pharmaceutical salespersons, or drug reps, during the 1990s. He describes in detail the pharmaceutical gift cycle, a three-way exchange network between doctors, salespersons, and patients and how this process of exchange is currently in a state of involution. This gift economy exists to generate prescriptions (scripts) and can mask and/or perpetuate risks and side effects for patients. With implications of pharmaceutical industry practices impacting everything from the personal-psychological to the global political economy, medical anthropologists can play a lead role in the emerging scholarly discourse concerned with critical pharmaceutical studies.

Risk, Vulnerability, and Harm Reduction

Based on long-term ethnographic research, Nichter explores how and why the use of antibiotics as prophylaxis has emerged as the main way that sex workers and their clients believe they can protect themselves from Sexually Transmitted Infections (STIs). Nichter’s research provides some excellent insights into the often noted disjuncture between behaviour and knowledge, arguing that while sex workers and their clients are indeed knowledgeable about STIs, they still make decisions that most public health practitioners would deem forms of ‘risky behaviour’.

In order to understand this, Nichter asks us to pay more attention to “popular interpretations of risk messages, personal perceptions of vulnerability, and practices adopted to reduce risk or decrease harm from STIs which lie outside the purview of public health guidelines (and wisdom)” (102). While public health practitioners often assume that more knowledge about risk will prevent risk, Nichter details how risk is deeply subjective and always understood in context, and therefore it is never just about ‘more’ knowledge, but knowledge that matters to people in their everyday lives. In this way, if we take a universal ‘rational-man’ approach to public health messaging, we miss the ways people situate and make sense of risk and risky behaviours in relation to their own personal circumstances, social and political relations, and notion of self-identity.

“The post-antibiotic apocalypse” and the “war on superbugs”

Discourses evoking an antibiotic apocalypse and a war on superbugs are emerging just at a time when so-called “catastrophe discourses” are undergoing critical and reflexive scrutiny in the context of global warming and climate change. This article combines insights from social science research into climate change discourses with applied metaphor research based on recent advances in cognitive linguistics, especially with relation to “discourse metaphors.” It traces the emergence of a new apocalyptic discourse in microbiology and health care, examines its rhetorical and political function and discusses its advantages and disadvantages. It contains a reply by the author of the central discourse metaphor, “the post-antibiotic apocalypse,” examined in the article.

Rethinking Informality

If informality has been conventionally understood as a territorial formation or as a labour categorisation, this paper offers an alternative conceptualisation that conceives informality and formality as forms of practice. The paper examines how different relations of informal and formal practice enable urban planning, development and politics, and explores the changing relationship between informality and formality over time. To illustrate the political potential of conceiving informality and formality as practices, it highlights the fall-out from a particular urban crisis: the 2005 Mumbai monsoon floods. In the final section, the paper offers three conceptual frames for charting the changing relations of informal and formal practices: speculation, composition, and bricolage.