La pharmaceuticalisation à ses marges
Alice Desclaux and Marc Egrot
— Reviewed by
Alice Desclaux and Marc Egrot, Anthropologie du médicament au Sud: La pharmaceuticalisation à ses marges[Anthropology of medicines in the South: Pharmaceuticalisation at the margins]. Editions L’Harmattan, 2015. 273 pp., 29 euro. ISBN: 978-2-343-05253-3.
In recent years, pharmaceuticalisation has been the subject of edited volumes (Bell and Figert 2015; Sismondo and Greene 2015) and numerous papers (Biehl 2007; Abraham 2010; Williams, Martin, and Gabe 2011; Cloatre and Pickersgill 2014; Collin 2016), but Anthropologie du médicament au Sud: La pharmaceuticalisation à ses marges [Anthropology of medicines in the South: Pharmaceuticalisation at the margins], edited by Alice Desclaux and Marc Egrot, is the first of its kind in French. Anthropologie du médicament au Sud elaborates on Williams’s description of pharmaceuticalisation as the redefinition of life situations in terms of opportunities for the pharmaceutical industry. The ambition of the book is to examine a wide range of situations, mainly in Africa, of the nonmedical use of pharmaceuticals from a local user’s perspective. This book is ‘a discussion of the relevance of the concept [of pharmaceuticalisation], forged in societies where there is overconsumption of medicines, to different situations in the South’ (p. 33).[note 1]My own translation.
Desclaux and Egrot are medical anthropologists and researchers at the French Institute for Development Studies (IRD) and have extensive experience in Africa. The collective volume, part of a new series entitled ‘Anthropologies & Médecines’, from the French publishing house L’Harmattan, involves a wide research network. The rich introduction reviews earlier research on medicines in Africa (Nichter and Vuckovic 1994; Whyte, Van der Geest, and Hardon 2002) and the rise of a new interest in global pharmaceuticals (see for example Petryna, Lakoff, and Kleinman 2006).
By sidestepping the usual research pathways that sometimes take for granted the reality and materiality of medicalisation or pharmaceuticalisation, this book gives interesting and original accounts that help nuance the use of the concept in specific spaces and times. To do so, the editors have identified ‘margins’ as their field of analysis. Four margins structure the book: payment, conventional procurement, medicine, and therapeutics.
The first section on ‘medicines at the margin of payment’ provides a good historical account about the exceptional positioning of medications in health systems. The Bamako Initiative placed user fees, especially through direct payment for medicines, at the centre of what was thought of as a community-based policy. Two chapters account for these experiences. It is the AIDS pandemic that brought back to the public health scene the user fee as a barrier to treatment and compliance. Bernard Taverne gives a ‘biography of a public health decision’ to provide antiretrovirals for free, a decision in which he and other contributors have been involved. Whereas this decision from the margin could have helped rethink the centrality of user fees, an interesting last chapter describes pro-user fee ideas, based on research led by Valery Ridde and Oumar Malle Samb.
Counterfeit drugs and parallel imports have been a growing issue for the pharmaceutical industry, which worries about their nonmarginal benefits and drug safety. In this section of the book, three chapters address informal pathways at the margin of formal drug procurement. This perspective is interesting because it puts the materiality of medications at the centre of uncontrolled processes. Pharmaceuticalisation then appears to be less about the power grids of the pharmaceutical industry than about a more complex process of social construction (see Baxerres in this book, and Peterson 2014).
The two last sections of the book move away from medical and therapeutic endpoints. Desclaux’s chapter about antiretroviral side effects highlights one important question about what Deleuze has named ‘audio-visual battles’ (Krtolica 2015). Are such unintended effects ‘side effects’ or are they ‘adverse effects’ (secondaires ou indésirable)? Essentially it takes us back to the basis of medication as ‘pharmakon’ (Persson 2004), that which helps but also harms, and the subtle dosage that delimits the therapeutic window above the level of efficacy and under the level of toxicity. More precisely, it is also about the medical gaze and its construction through the very definition of margins. In this sense, the margins, such as side effects, are important to think of as ‘leftovers’, as that which cannot always be integrated into the construction of therapeutic strategies. This is significant for two reasons: first, side effects have an important impact on people’s subjectivity (Gagnon 2010), and second, broader scientific fictions such as ‘disease eradication’, which bring those leftovers into being, leave those margins invisible. On the downside, presenting these side effects as linked to representations – the side effects of lipodystrophia, for example, seem to be ‘less important’ in patients’ lives in Senegal than in the North – might leave aside the questions about their political economy. Drug patent processes, which make some molecules available and others not, restrain doctors’ choices and sometimes produce a double standard of care, in obvious contradiction with ‘treatment for all’ international slogans.
Anita Hardon’s chapter provides a comparison of contraceptive use in three countries, showing that medication use happens between the ‘technical script’ of medication and local practices and representations. Pharmaceuticalisation appears then as anything but a straightforward normalizing process. Injectable contraceptives are mostly used in South Africa because of their potential invisibility, given a social context where pressure to have children is high, explains Hardon. As a result, even though this injectable technology was intended for poor women who would not be able to take regular oral contraceptives, the example shows the innovative ways in which people reconfigure the technical script in relation to particular social contexts.
Finally, this book is an important contribution to the field of anthropology of medication and the margins, as these sites for observation turn out to be revealing. Other margins, such as global philanthropy, public–private partnerships, nongovernmental organisations, medical experiments, and clinical trials, can also help ‘provincialize’ the concept of pharmaceuticalisation in slightly different ways. To the end, this collective volume allows us to think about unusual and diverse pathways regarding pharmaceutical uses, and questions the application of pharmaceuticalisation as a theoretical apparatus in Africa. This book has the advantages of building on the heuristics of pharmaceuticalisation and avoiding the pitfalls of its incautious use regarding local social contexts.
About the author
Pierre-Marie David is a sociologist and pharmacist, and is currently a postdoctoral researcher at the University Paris Diderot. He is also a lecturer at the Faculty of Pharmacy, University of Montreal, in the Department of Medications and Population Health, and an associate researcher with the research group Méos (Medications as social objects).
Editors’ note: This review was slightly edited after publication to clarify the authors’ professional backgrounds and to correct the title of the series to which this volume belongs. The
Abraham, John. 2010. ‘Pharmaceuticalization of Society in Context: Theoretical, Empirical and Health Dimensions’. Sociology 44, no. 4: 603–22.
Bell, Susan E., and Anne E. Figert. 2015. Reimagining (Bio)Medicalization, Pharmaceuticals and Genetics: Old Critiques and New Engagements. New York: Routledge.
Biehl, João Guilherme. 2007. ‘Pharmaceuticalization: AIDS Treatment and Global Health Politics’. Anthropological Quarterly 80, no. 4: 1083–26.
Cloatre, Emilie, and Martyn Pickersgill. 2014. ‘International Law, Public Health, and the Meanings of Pharmaceuticalization’. New Genetics and Society 33, no. 4: 434–49.
Collin, Johanne. 2016. ‘On Social Plasticity: The Transformative Power of Pharmaceuticals on Health, Nature and Identity’. Sociology of Health & Illness 38, no. 1, 73–89.
Gagnon, Marilou. 2010. ‘Femmes vivant avec le VIH/sida et lipodystrophie: vers une compréhension qualitative du processus de transformations corporelles’. Aporia 2, no. 3: 32–40. http://www.ruor.uottawa.ca/handle/10393/12946.
Krtolica, Igor. 2015. Gilles Deleuze: ‘Que sais-je?’ n° 3964. Paris: Presses universitaires de France.
Nichter, Mark, and Nancy Vuckovic. 1994. ‘Agenda for an Anthropology of Pharmaceutical Practice’. Social Science & Medicine 39, no. 11: 1509–25.
Persson, Asha. 2004. ‘Incorporating Pharmakon: HIV, Medicine, and Body Shape Change’. Body & Society 10, no. 4: 45–67.
Peterson, Kristin. 2014. Speculative Markets: Drug Circuits and Derivative Life in Nigeria. Durham, NC: Duke University Press.
Petryna, Adriana, Andrew Lakoff, and Arthur Kleinman. 2006. Global Pharmaceuticals: Ethics, Markets, Practices. Durham, NC: Duke University Press.
Sismondo, Sergio, and Jeremy A. Greene. 2015. The Pharmaceutical Studies Reader. Chichester: John Wiley & Sons.
Whyte, Susan Reynolds, Sjaak van der Geest, and Anita Hardon. 2002. Social Lives of Medicines. Cambridge: Cambridge University Press.
Williams, Simon J., Paul Martin, and Jonathan Gabe. 2011. ‘The Pharmaceuticalisation of Society? A Framework for Analysis’. Sociology of Health & Illness 33, no. 5: 710–25.