Scientific Sovereignty and Pharmaceuticalization in Two International Drug Donation Programs
Political Narratives
Drought and the memory of water mark the hills near Gairo, in the Morogoro region of Tanzania. I am sitting with my friend Donatus, a bilingual Tanzanian nongovernmental organization (NGO) consultant, and a village health officer named Penford.1 We are discussing the spectral, puzzling presence of two huge international drug donation programs, the Mectizan donation to treat river blindness and the Zithromax donation to treat trachoma. The programs have reached from high-tech labs in New York and New Jersey all the way here to East Africa, and they have marked and changed local people, local systems of knowledge and local power structures. They have done this by providing free drugs. Our conversation went like this:
Donatus: Well, there’s a program starting, you heard what President Kikwete said right?
Penford: What did he say?
Donatus: That every village should have its own dispensary.
Penford: I have heard that.
Penford and Donatus continued, back and forth, joined by a woman who also served as a village health worker and a man who is a member of the village council. I sat silently, listening, taking notes, watching each speaker in turn.
Penford: It is true that this program [the drug donation] has come to help us. We agreed, and we still agree, to serve our community [by volunteering for the donation]. But at least they should look at our case. We have agreed to serve the community, but there should be at least something small for us, for all the work that we are doing.
Donatus: For what you are doing for the community?
Penford: Yes. The drugs come once a year, and they gather us together in a seminar and that is the only time that they give us something. Twenty-five hundred shillings [about US$1.50]. They should give us something better.
Council member: Before he answers our visitor: this is a community project, OK? It is a project that has been brought to the community, and the community members must realize that it is their responsibility to look after the people who are helping them, the drug distributors. The government, together with the donors, has brought this service to the people, just like a school. They knew that you could not afford the drugs, so they have brought you the drugs, just like they give you teachers and other things for development. So that’s why they are saying that the village [instead of the international drug donation program] should find a way to remunerate the drug distributors. The government supports you in giving you drugs, transporting the drugs and educating you all so you know about the drugs, how they work and how to take care of them. And the importance of the drugs. That’s what I understand, and that’s the reality.
Penford: That’s just politics.
Council member: No, it’s not politics.
This conversation and the story told in it can shed light on cracks and fissures of unjust political and social structures located in a complex web of global health inequality.2 It echoes a story recounted by Didier Fassin in When Bodies Remember. Fassin relays the words of a woman named Puleng, a South African who later died of complication from AIDS, alone in a subterranean apartment in a township (Fassin 2007). Without much prompting Puleng told Fassin her life story, a narrative filled with pain, with missed chances and cruelty; she told Fassin this story not to elicit his pity, but to illuminate the injustice of what happened to her, and what was happening to so many others around her. I recount the previous conversation, and some of the following narratives, in a similar interpretative spirit. Like Fassin, I am interested in how these stories, told spontaneously and with a certain degree of frank self-interest, can trouble and add to technical narratives of the life of these two international drug donation programs. I follow Fassin here, among many other ethnographers and anthropologists, in trying to make many parts of a complex story speak to and with one another, and specifically in trying to put together a hybrid political narrative, a bricolage of voices from many actors (organizers, recipients and scholars of these international humanitarian interventions) that attempts, in a spirit of respectful criticism, to chart and examine the “unspoken orthodoxies” (Stirrat and Henkel 1997) that drive the donation programs.
In 2006, I spoke over lunch with a research scientist on the Zithromax team in New London, Connecticut. We sat in an alcove drinking coffee; he had walked me there from his office, led me there in fact, because the interior of the building lacked signs or other points of reference. Its architects had designed it with curved walls and disorienting starts and stops, none of the usual furniture of a working office; this was supposed to provide a physical impediment to espionage.
The Zithromax Donation Program is massive – 225 million doses have been distributed to date (International Trachoma Initiative 2014). The researcher was excited about his corporation’s charitable work; he was excited that a product with which he strongly identified himself was being given away, and was being absorbed so usefully into so many bodies. He asked me why I hadn’t asked why his company didn’t donate more drugs or other drugs, then provided an explanation as if I had. He argued that if the corporation began donating all its drugs it would “shut its doors” within a year or two, and would be unable to pay its researchers, or to continue manufacturing its existing products. Total donation, in the researcher’s view, would remove the corporation from the sustaining cycle of for-profit research. Of the recipients of this hypothetical largesse the researcher said, “They will live – and their children will have no chance at a better life.” In the researcher’s conception the continual innovation of the pharmaceutical industry promised to provide this “better life,” and it could not do so without commercial structures of profit.
This statement among many other similar ones led me to ask two questions that I hope will help connect drug donation programs to ideas of property and ownership. We know that the donation programs are organized around giving, but one of my questions follows Mauss, Godelier and Weiner in asking, “what do the donations keep?” (Weiner 1992; Godelier 1999; Mauss and Halls 2000). The other asks, “what do the donation programs say about public and private property in humanitarian interventions?” The answers to both questions reveal the paradoxically conservative nature of the donation programs. Although they are novel and create new relationships (not exactly partnerships, as in the Harvard public health scholar Michael Reich’s work on public-private partnerships, 2002), they do so in tune with the well-worn values of neoliberal capital. They appear to be yoking private industry and public service, but they do not, or they do so in a way that reaffirms public and private identities, rather than bringing them into question.
In the many narratives of the history of the drug donation programs I collected in my fieldwork, the same few themes emerged from the multiply-positioned speakers: the surprising power of the drug, the complex process of marrying a donated pharmaceutical product with a disease and a treatment or control technique (on the scale of public or global health) and finally the construction of new organizations or partnerships to administer the donation. I sketch these processes here for the two drug donation programs in this study.
Ivermectin and River Blindness
In 1988 Daniel Bishop, then the CEO of Kurtis Pharmaceuticals, inaugurated an international donation of the drug Ivermectin, or Mectizan, for the control of river blindness, also called onchocerciasis. Ivermectin is a deworming drug that Kurtis initially developed for veterinary use, then later adapted to control human parasites. Ivermectin controls and cures river blindness with one yearly dose. The drug reaches its recipients through a complex network of organizations involving client governments, international blindness NGOs, a purpose-built foundation/NGO called the Mectizan Donation Program and of course the drug company itself. Since the 1980s the model of drug donations disbursed through mass drug administration has become increasingly important in global health.
Ten years later, in 1998, Williams Pharmaceuticals began its own drug donation program. Williams gives away the antibiotic Azithromycin (Zithromax) to control trachoma, a blinding bacterial eye infection endemic to Africa and parts of Asia. Williams’ donation relies on a public health technique called the SAFE strategy (Emerson et al. 2006). SAFE combines medication with corrective surgery and a few simple hygiene techniques (face washing and “environmental” cleanliness, usually referring to digging and using communal latrines and tidying households) to cure and control trachoma. Williams partnered with the Edna McConnel Clark Foundation to create the International Trachoma Initiative, an NGO tasked with disbursing the donated drug.
In order to chart and understand both of these programs I spoke with retired and current pharmaceutical, foundation and NGO executives, attended seven international meetings of disease-control experts, and visited Tanzania, where I met with regulatory, NGO and Ministry of Health officials, and interviewed Tanzanian citizens in the Morogoro region. Some of these local people volunteered for the donation efforts, and some simply received the drugs as part of the yearly distributions. I did this research between 2006 and 2009; I was in Tanzania in September and October of 2007.
One of my enduring interests in this research was charting what the provision of donated pharmaceutical products did to personhood, citizenship and the human body, on a literal and also on an epistemological scale; that is, I wanted to understand what impact the donation programs had on the imagination of what is possible in global health. It was very clear from the beginning that the drug donation programs, which made extreme claims on the stage of global health and development (see Amazigo 2008; International Trachoma Initiative n.d.), were part of an emerging global trend of pharmaceuticalization. The programs struggled constantly, on the level of operations and also on the level of self-presentation and PR rhetoric, with the extent of their mission and whether what they were doing was “merely” drugging, or whether they could claim a more comprehensive humanitarian effect. What’s more, on a political and global level, they were treating a highly multifactorial problem (the ill health of the world’s poorest) as essentially a technical challenge. This technical challenge was even more narrowly framed as a specifically medical challenge, and more specifically still as pharmaceutical one.
Actors situated at different parts of the donation projects expressed different opinions on the issue of what exactly the drugs were doing and who they benefited (the drug companies, international NGOs, the recipients, client ministries of health). The same actors told the story from multiple points of view. Others, like Nathan Rangan and Mohammed Bahraini of the International Trachoma Initiative, emphasized broad development benefits when they told me proudly that their donation programs benefited young women and girls particularly, since they prevented blindness and thus freed socially subordinated family members to go to school. This allowed some rhetorical room to maneuver within the narrow field of responsibility of the programs; program officers could speak about development without taking responsibility for it.
In the rest of this chapter, I chart some of the ways in which human bodies and the drugs that affected them took center stage in the rhetoric of the donation programs. I explore what is at stake when a large corps of developed world health professionals harnesses the economic, biomedical and political power of pharmaceuticals to elaborate and export a notion of the body that does not necessarily match local ideas in the developing world.
What Is at Stake in the Donation Programs?
The key to understanding how the donation programs engage with publics and imagine their own work is analyzing their technical practices and rhetoric. The Mectizan Donation Program uses a technique called CDTI (community-directed treatment with Ivermectin); the Zithromax donation relies on a similar technique called SAFE (standing for surgery, antibiotics, face washing and environmental cleanliness). Both drugs cure other diseases, especially Zithromax, which is a broadly useful antibiotic (interlocutors in Tanzania reported grinding the pills up and rubbing the powder into cuts, for instance; they also told me that they knew they were not supposed to do it). But in these drug donation programs, the drugs are not for patients; they are for regions made up of bodies marked by a particular global public health logic (see also Frost 2002 for a discussion of conflict between patient and population in the early days of the Mectizan donation).
The central approach for both donation programs is usually called a “mass drug administration.” Mass drug administration’s basic requirement is that the drug must be consumed by the entire eligible population. In these two donation programs, the drugs are administered only once a year. Populations become eligible based on geographical surveys of disease endemicity – for example, in the case of onchocerciasis, practitioners measure this endemicity through a technique called REMO, rapid epidemiological mapping of onchocerciasis (Noma et al. 2002). In both donation programs, the geographic areas must demonstrate an endemicity higher than a certain arbitrary threshold (20 percent in the case of onchocerciasis); once this threshold is reached, all members of the community receive the drug, whether or not they actually have the disease.
As we drove from Dar es Salaam to the Morogoro region to conduct interviews I asked Donatus, who had worked closely with onchocerciasis and trachoma control programs in Tanzania for years, what the Kiswahili word for participants in the donation programs was: “wamezadawa,” he told me, meaning “drug swallowers.” The word recurred in the rest of my fieldwork in Tanzania – in the offices of the Tanzania Food and Drug Administration, the Ministry of Health, at clinics and dispensaries at which we paid courtesy calls on the way to the five villages in Morogoro and in conversation with village health workers and ordinary people who received the donated drugs. The technical and popular discourse of the drug donation programs did not meaningfully characterize the targets of international health aid as patients or citizens, people with rights or desires or thinking, acting subjects. The name for donation recipients in Tanzania, “wamezadawa,” “drug swallowers,” derived from the powerful goods that they received, and from a narrow understanding of what they ought to do with the drugs.
The Mectizan Donation Program for river blindness approaches the individual body as a site of area-based, highly pharmaceuticalized public health. My interlocutors at Kurtis and at various NGOs explained to me that adult Onchocerca volvulus worms encyst themselves in their victim’s skin, creating the nodes measured by palpation. These cysts cause little harm or discomfort by themselves, but the adult worms also produce multitudes of microfilaria or juvenile worms, which chew their way through the skin and the tissues of the eye, causing horrific itching and, eventually, blindness. The drug Ivermectin paralyzes the microfilaria but does not necessarily kill the adult worm. Since Ivermectin does not kill the adult, a single mass drug administration will not eliminate the disease from a community or from an individual – the adults will, theoretically, survive and give birth to new microfilaria. The encysted adult worms die of old age after about fifteen years. Program administrators and researchers have therefore concluded that fifteen years of yearly treatment with Ivermectin will ensure that the adult worms leave this earth without reproducing, and therefore the disease will be eradicated from an area (biomedical evidence supports this idea; see Diawara et al. 2009).
By dosing individual bodies with drugs the organizers of the donation hope to “cleanse” an area; human bodies become a feature of the natural landscape, an expedient way to come to grips with a foe that lives in a specific region. Previous scholars have noted a reductive impact on healthcare, in which provision of drugs becomes the main mode through which patients experience medical care and, in many cases, the state (Biehl 2004, 2013). In the drug-based environmental hygiene project of the Mectizan donation, we see a pharmaceuticalization of the environment, a way of acting upon natural features of an area, a population of harmful parasites, and the massed bodies of a population all at once, ostensibly for a period of at least fifteen years.3
“As if We Were Developing Any Profitable Drug …”
As I began to learn about the drug donation programs, I wondered how these tropical or global health efforts fit into the corporate structures of the drug companies. It was clear that Big Pharma was willing to spend enormous amounts of money and effort on these health interventions which, unlike other drug company projects, never promised to yield any profit. How could the authors of the donation reconcile this with their responsibility to manage a for-profit corporation? I saw this question, which my interlocutors never fully or clearly answered, as another way of looking at how the donation programs operated on the imagination of what is possible in global health – and what is possible for corporate charity.
I began research into the world of pharmaceutical donations by talking with policy researcher Laura Frost, who was then a visiting scholar at Princeton’s Woodrow Wilson School. Frost had an extensive background in drug donations, having worked closely with leading public-private partnership scholar Michael Reich at Harvard. She told me succinctly and powerfully that mass drug administrations have more going on beneath the surface than one might think – “donations aren’t free.” Frost’s work focuses on the donation of Mectizan, explores early conversations between Kurtis Pharmaceuticals and the World Health Organization (WHO), and charts how the two organizations strove to reconcile corporate cultures and to iron out the difference between treating individual patients (that is, patients with many rights, in a clinical setting) versus conducting a mass drug administration (Frost 2002). The ex-CEO of Kurtis Pharmaceuticals told me a strikingly different story of Mectizan. His account of the early days of the drug donation program reveals the roots of the orthodoxy that places drugs at the center of a massive, continually growing global health intervention that still operates today. I met with Dr Daniel Bishop, who was CEO of Kurtis when the donation began, in his suite in an unassuming corporate park in suburban New Jersey, not too far from Princeton and New York City. Although Bishop is retired, he maintains this one-man office suite, marked only by his initials on a brass plaque, complete with a receptionist and a tiny waiting room. His actual office is spacious and beautiful, decorated with a career’s worth of awards – I was relieved when we sat around a small coffee table instead of on opposite sides of his imposing desk. Bishop had responded eagerly to my email inquiries about the Mectizan donation. I was to learn that this was one of his proudest accomplishments.
When research on Ivermectin began, Bishop was head of Kurtis’ labs; he became CEO later, after distinguishing himself as a superb research director, a man who bridged corporate and scientific interests and attracted and fostered incredibly talented pharmaceutical researchers.4 Bishop began the story of the Mectizan Donation Program with the origin of the drug itself, as a veterinary dewormer, an antiparasitic for livestock and pets. He repeatedly called it “an amazing drug” – “the most important animal health drug in history.” Bishop told the story of the drug’s movement into the world of global health avidly and passionately. He spoke rapidly, with emphasis, clearly, fluently, as if he had told this account before many times but still became bound up in the telling:
Initially we had high hopes that this drug would be important for humans. Because it was an exciting antiparasitic, which had unusual potency. It was probably 100 times more potent than the latest, most exciting drug for killing parasites. So we quickly looked at, investigated all the parasites that might be sensitive to it. All roundworms essentially were sensitive to it, so it was clear that it could be an important drug for all kinds of mammals that have roundworm parasites. We also looked at hookworms and tapeworms in humans, that were important parasites in humans, and they were not very sensitive, so it early became apparent that it was not going to be, it might not be important for humans, so it was essentially put on the shelf.
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