Pharmaceuticals and Markets

There are stories behind the ways we use antimicrobials across the world today. These are not only stories of medical science or of happenstance but also of economics and politics.

The presence of carbapenems in grocery shops in India can be understood as a story not only of local markets or supply and demand, but also a story of ‘pharmaceuticalisation’ and global ‘individualisation’ of the self. Tracing the multitude of contexts within which antimicrobials are prescribed, sold, and traded involves exploring the nature and scale of markets as shaped by specific histories and political economies.

On a local scale, anthropologists have produced over the past four decades a substantial body of work on the flow of antimicrobials through informal spaces including ‘drug shops’, through social networks, and via experimentation outside the lab on farms and in homes. These informal channels are often denigrated as dangerous peddlers of antibiotics and information, but these sources of care have been shown to have important functions in fragmented health systems (Whyte, Van der geest and Hardon 2002). Furthermore, the distinction between ‘informal’ and ‘formal’ is often blurred. For example, patients often seek treatment from those on the ‘edges of legitimacy’ (Pinto 2004), and formal pharmaceutical companies often rely on ‘informal’ shops to sell their antibiotics where formal channels are tricky to access.

On a global scale, antimicrobials operate within the business models of the multinational pharmaceutical industry. Anthropologists have written extensively on the ways in which the operationalisation of these modesl has shaped approaches to disease and health. For example, one of the unintended consequences of scaling up international action on health – from malaria to HIV/AIDS treatment – has been observed as “the consolidation of a model of public health centred on pharmaceutical distribution” (Biehl, 2007:84) rather than prevention and/or clinical care. For many in the Global South, while pharmaceuticals are becoming more widely available, it can still be impossible to actually see a physician when visiting a public health clinic. Many social scientists now refer to this shift in health delivery as the ‘pharmaceuticalisation’ of public health (Biehl 2007, 2013; Petryna et al. 2006; Lakoff 2005; Oldani 2004).

The concept of pharmaceuticalisation emerges from the related term medicalisation, which can be understood as the encroachment of biomedicine into areas of life hitherto considered in the domain of the social, such as childbirth. Both concepts represent processes through which the context of health and care can be stripped away; through which political, economic, and social determinants of health and of care are obscured by approaching disease and treatment in exclusively biomedical terms (Biehl 2004, Conrad 2007; Davis 2009; Scheper-Hughes 1992). In addressing AMR, the concept of pharmaceuticalisation is useful to consider in orienting questions around the consequences of AMR, and of reducing our reliance on antimicrobials.

What is striking about AMR is that by indicating the overuse of medicines, it brings to the fore how pharmaceuticalisation has largely gone unchallenged. Yet, rather than disrupting pharmaceuticalised forms of care that rely on antibiotics to manage health, much of the AMR discourse enlivens pharmaceutical markets. AMR campaigns emphasise the centrality of pharmaceuticals in healthcare, rendering them even more desirable. Policy typically encourages investment in new kinds of antimicrobial medications, as well as other complementary technologies of rapid diagnostic testing, and laboratory upgrading.

Anthropological research, then, has attempted to situate medicines as they are prescribed, sold, and traded within local networks of relations embedded in particular histories, legacies and political economies.

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