Fake-talk as Concept and Method

What’s at Stake in the Fake? Indian Pharmaceuticals, African Markets and Global Health

— Julia Hornberger, Sarah Hodges

Published: 27 September 2023

Fake Pharmaceuticals Health Evidence Suspicion

https://doi.org/10.17157/mat.10.3.7291

Abstract

In a world seemingly awash with fakes—or at least accusations of fake-ness—it is not only difficult to discern what is ‘real’ but also to know what to make of such a proliferation of worries about fakes. In this article, a manifesto of sorts for the Special Section, we outline how the problem of ‘fake drugs’ in particular allows us to understand the phenomenon of fakes in general. We introduce the conceptual and methodological tool of ‘fake-talk’ as it allows us to make sense of claims about fake drugs and of the power these claims hold. We develop our argument through a close reading of specific ethnographic examples drawn from the work of our colleagues in the project ‘What’s at Stake in the Fake? Indian Pharmaceuticals, African Markets and Global Health’. We show that fake-talk thrives on a lack of evidence, imports urgency, and is expressive. Taking fakes seriously as a force in themselves enables us to see how fakes are freighted with—and deploy—everyday articulations of otherwise unfathomable discomforts, predicaments, and anxieties of our time.

Introduction

‘Genuine fake drugs can be hard to track down’. That was the message we took away from our conversation with the senior pharmacologist. We were sitting in a meeting room furnished with a whiteboard and a long boardroom table, talking with the soft-spoken chief designer of one African nation’s real-time drugs-quality monitoring and surveillance system.

In addition to designing the system, this pharmacologist and civil servant oversaw the rollout of his system’s data collection. He sketched out for us how this worked. At the start of each week, his team of ‘mystery shoppers’ would receive his instructions and fan out across the country’s major cities. There, they would visit marketplaces and pharmacies and buy individual packets of select over-the-counter and prescription-only medicines, such as antimalarials or antibiotics. By the end of the week, they would return to the study’s headquarters to hand their carefully labelled samples over to the country’s central pharmacology lab technicians. In turn, the lab employees would take note of the packaging and analyse the contents to see whether the tablets contained the required amount of active ingredients. By the end of the week, the senior pharmacologist would have examined the data and written a report of the week’s findings to be discussed at a meeting the following Monday.

Every Monday morning, the senior pharmacologist went on to explain, his boss would enter the meeting room in the government offices and greet the assembled officials with the single instruction: let this be the week the team finally finds the fakes. But each week the report would be the same: the essential and life-saving medicines that had been amassed by the team of ‘mystery shoppers’ and then tested by lab technicians did, in fact, meet the required standards. Deflated, his boss would promptly draw the meeting to a close, dismissing his underlings and urging them to go forth and find the fakes.

The pharmacologist’s boss had a hard job. He needed to craft a particular story about fake drugs: that of identifying the level of fake drugs in his country and rooting them out. Furthermore, he had to demonstrate certain technical abilities that would allow his country to join an international community in approved levels of pharmaco-vigilance. However, without good evidence of a fake drugs problem to begin with, performing the rest of these duties was virtually impossible; and without a documented tale of improvement, this African nation would not be in a position to receive lucrative pharmacovigilance and drug import contracts that were being secured in the region at the time we met.

Internationally, concerns about all kinds of fakes abound. From cases of fake fine wine said to lie in the cellars of high-stakes collectors, to rumours of fake fine art hanging in flagship museums and YouTube videos helping consumers avoid the many fake luxury handbags purportedly circulating in designer boutiques, we are now mired in uncertainty when confronted with questions of authenticity. Alongside such concerns, the last few decades have seen researchers and policymakers raising the alarm about the growing threat fake pharmaceuticals pose to global health. Often they frame their concerns in terms of particular places and people, such as with the claim that fake drugs from India are imperilling the health of Africans. Indeed, this latter assertion has been repeated so often and with such certainty that it has achieved a status of the self-evident. However, as the case of the senior pharmacologist in the anecdote above reminds us, genuine fakes can be very hard to find.

In our initial research to try and establish the evidentiary basis of these concerns about fake drugs, we subjected high-profile and oft-repeated public health claims in the scientific, policy, and popular literature to close scrutiny, paying attention to their sources and data. This scoping exercise produced some unexpected findings (Hodges and Garnett 2020) and revealed far more questions than answers, including widespread uncertainty regarding what exactly constitutes fake drugs, how prevalent they are, what threats they may pose, and where they come from. In sum, we found no consensus supporting claims about the dangers posed by fake drugs.

A distinct, if related, problem that we and others have raised is a lack of definitional clarity (Baxerres 2014, 2015a, 2015b; Cloatre 2016; Hodges and Garnett 2020; Hornberger 2018; Quet 2017). Public health scholars and policymakers struggle to agree on a fixed definition when faced with the question: what actually are fake drugs? Since the 1980s, many in the policy world have invented new terminologies in the hope that the perfect term would overcome misunderstandings of the true nature of fake drugs. These terms have ranged from ‘counterfeit’ drugs to the more recent ‘SSFFC’ (standing for ‘substandard, spurious, falsely labelled, falsified, and counterfeit’) drugs to, finally, the current (at the time of writing, that is) ‘substandard and falsified’ drugs (see Sirrs, this issue). Yet confusion about what a ‘fake drug’ actually is stubbornly persists.

In practice, people across the spectrum of pharmaceutical experts, manufacturers, retailers, and consumers continue to use a wide range of terminologies to describe fake drugs. Sometimes drugs are called ‘fake’ because they have expired; sometimes they are called ‘fake’ because they are smuggled over the border from a country where they are licensed, into a country where they are not; sometimes drugs are assumed to be fake because they are available in marketplaces rather than in pharmacies; and sometimes suspected fake drugs are tested in a lab and found to contain the wrong amounts of ingredients according to the standards of one country but not those of another. Thus, these terminologies connote very different sets of circumstances and pose very different threats. ‘Unlicensed’ drugs are seen to pose a threat to a government’s tax revenues; ‘counterfeit’ drugs are seen to violate intellectual property laws and thereby pose a threat to a manufacturers’ market share; and ‘sub-standard’ drugs are seen to contain the wrong amounts of ingredients, thus posing a risk to their efficacy.

Together, these on-the-ground, messy realities concerning the production, circulation, and regulation of pharmaceuticals point to a larger problem: that of meaning. Claims of authenticity are fraught because they are contingent on so many factors that lie far beyond what can be captured by the test kits used in labs like that overseen by the senior pharmacologist mentioned above. Indeed, it appears that everyday definitions of fake-ness may lie beyond pharmacological ways of knowing.

Despite the persistent and widespread failure to capture either the prevalence of fake drugs or the nature of what exactly it means to be one, or what kind of threat they pose, claims about—and, indeed, beliefs in—the ‘truth’ of fake drugs persist. It is here that our inquiry begins. We are intrigued by this persistence. We are intrigued by the fact that accusations of fake-ness seem to thrive despite an apparent lack of evidence. We are intrigued by fakes’ very ontological fuzziness and imprecision. And so we ask: why does the threat of the fake drug continue to circulate and grow in power? What is going on? As medical humanities scholars, we leave the question of pharmacological evidence to those in the public health and policy realms. Instead, our investigations and analyses focus on the everyday social worlds beyond labs or legislatures, where claims about fakes flourish and take on lives of their own.

What we are arguing is that fake drugs are good to think with—for the question of drugs, as well as for all fakes. The supposed danger of fake drugs has been so widely and regularly rehearsed that the urgent threat they pose is now taken as self-evident and commonsensical. But what actually is the “danger of fake drugs” that we see invoked so widely? One way to understand it is through the idea of a gift: as much as drugs are seen as a potent gift to the health of humanity (Porter 1999), the spectre of fake drugs is its insidious reversal. Once suspected of being fake, a drug becomes invested with the power to kill. In other words, what studying concerns about fake drugs has shown us is that the danger of fake drugs is the danger of a deadly public health crisis. This holds a significance beyond simply pharma. Worries about the urgent threat posed by fake drugs matter more broadly. With other kinds of fakes, such as handbags or wine or fine art, any imminent danger is far from obvious. But, energised by the spectre of fake drugs, concerns about all kinds of fakes can be fuelled by the imagined urgent threat of a public health emergency. The spectre of fake drugs makes plausible the idea that all fakes are dangerous. Fake drugs are emblematic of all fakes.

This, perhaps surprising, dynamic—that fake drugs index the danger for many, if not all, fake goods—is best illustrated through an example from our own research. In 2019, South Africa was the first African nation to host the International Law Enforcement Intellectual Property Crime Conference. Organised by the international policing agency Interpol, the conference rehearsed what has come to be the conventional choreography of international intellectual property (IP) policing: it held up cases concerning fake drugs as exemplary justification for how and why to police all kinds of fake goods. Fake drugs captured the attendees’ imagination. In what might otherwise have been a staid set of procedural conference presentations, the spectacular case of fake drugs demonstrated the visceral urgency and danger of all fakes. The conference presentations also echoed headlines in the popular and expert media that regularly and spectacularly exclaim that ‘Fake Drugs Kill’. Fake drugs were given prominence even though, for the great majority of speakers and police in this conference and across global IP policy, only rarely are fake drugs the main targets of anti-counterfeit policing. Instead, the policing of fake DVDs or fake sneakers is policing’s daily bread. Drawing out their equivalence, however, leaves no doubt in people’s minds that all fakes present urgent threats and are therefore deserving of public monies and crime-fighting efforts (Hornberger 2018, 2019).

Fear mobilised by the threat of fake drugs animates all fakes because fake drugs cathect an urgency to react. This urgency, combined with the messiness of fake drugs’ undetermined meanings, unfetters actors from any need for evidence that might prove the ‘certainty’ of fake-ness. To think carefully about fake drugs, then, allows us to come to grips with the question of why and how claims about all kinds of fake-ness thrive. The following sections elaborate and set out the evidence for this claim.

Why all this interest in fakes now?

Once we started thinking about fakes and drugs, we could not stop. In her research with local police across several Southern African countries, Julia’s ethnographic research into how a global campaign of anti-counterfeit policing played out in Africa led her to fake drugs. Julia became fascinated by how, under the new ‘drug security’ paradigm, police never found actual fake drugs. Police did, however, effectively harness the resources and moral standing that participating in this global campaign provided. Rather than attempting to push back against or clarify the distance between global campaigns and the reality of their local beat, police used the fight against fake drugs to advance hyperlocal concerns, underwritten by the unusually urgent and clear moral purpose that came with fighting fake drugs (Hornberger 2018, forthcoming).

Sarah’s work on fakes began with following the legal case of a so-called spurious drug kingpin in India (Hodges 2019). She was surprised at the lack of evidence of the existence of fake drugs in a case that was supposedly all about fake drugs. She thought this lack of evidence must have been an exception, or at the very least, unusual. Yet, when she and another scholar examined the health and health research literature, they found that, in fact, a lack of hard evidence of ‘genuine’ fakes was typical (Hodges and Garnett 2020). Instead of providing evidence of fake drugs posing an urgent public health threat, scholars used proxies such as a bad batch of skin-lightening products in articles about life-saving drugs.

Having started out like moths attracted to the flame of the fake drug and the puzzles it posed—especially that of how unsubstantiated claims of fake drugs were repeated as truisms—we soon lifted our heads to take in the wider context of this phenomenon. As we did, we were struck by how much our inquiries were embedded in a particular historical moment. While questions about fake-ness, fabrication, and authenticity have circulated for centuries (Tattersall and Névraumont 2018), fakes and claims of fake-ness saturate our current historical moment. The logic of global commodity capitalism is central to both the perceived proliferation and the condemnation of all things fake (Pang 2008; OECD 2007), and pharmaceuticals are a celebrated case of this dualism. Since the late 20th century, the careers of pharmaceuticals have flourished in volume and in value, as part of what is often referred to as the ‘pharmaceuticalisation of life’ (see e.g., Abraham 2010; Dumit 2012). We were also struck by the simultaneous flourishing of worries about pharmaceuticals—particularly that they are being copied willy-nilly by criminals in the pursuit of easy profit (IMPACT 2011).

This twinned growth of pharma markets and fakery worries have both generated and been generated by a reconfiguration and elaboration of global policing regimes around intellectual property (IP), principally through the Trade-Related Aspects of Intellectual Property Rights (TRIPS) Agreement and multiple regional trade agreements (Mayne 2005). In this reconfiguration of international trade and its corollary policing regimes, pharmaceuticals take pride of place because (as we have explained above) they bring a moral urgency to the policing of markets. This is no small thing, as the elaboration of the policing of markets has taken place against the ambient noise of seemingly ubiquitous humanitarian crises. These crises matter for our understanding of the problem of fake drugs because they have mainstreamed the mode and language of urgency to authorise interventions (Calhoun 2004). In this historical moment in which global commodity capitalism, international policing, and humanitarian interventionism come together, the dramaturgy of the fake drug becomes recognisable as a crisis in its own right.

Having grasped this larger context of the fake drug, we realised that within this literature, scholars hew to one of two positions. One set of scholars casts a highly sceptical eye on the problem or imminent danger of fake drugs. Their analyses show how concerns about fake drugs have historically been very closely tied to criticisms of low-cost generic drugs, and how concerns about fake drugs have functioned to protect big pharma’s lucrative markets rather than to ensure patient safety.

Here, Kaushik Sunder Rajan’s work is a key example. In his Pharmocracy: Value, Politics, and Knowledge in Global Biomedicine (2017), Sunder Rajan explores India’s career in the international political economy of pharmaceuticals. Whether by recounting the role of Indian pharmaceuticals in the AIDS crisis in Africa or the career of Indian pharmaceuticals’ patent law, he tells a story of the Indian state holding up the value of public health against the interests of international capital. In speaking of a partisan state, he casts those who would criticise Indian drugs’ quality standards as merely parroting the interests of so-called Big Pharma.

A second set of scholars take claims about the dangers of fake drugs at face value. Here, we turn to Kristin Peterson’s Speculative Markets: Drug Circuits and Derivative Life in Nigeria (2014) as an example. Peterson grounds her analyses of the international political economy of pharmaceuticals in a multi-scalar ethnography of the production, distribution, and trade of pharmaceuticals in Nigeria in the wake of economic crises precipitated by structural adjustment programmes. Through her analysis, she explains the emergence of the spectre of fake drugs in Nigeria. However, fake drugs in her analysis function as a data point in her ethnography, not as an object of inquiry. Rather than interrogating the truth value of the claims her ethnography uncovers, she asks questions about how Nigeria happened to be such a dynamic field for the unravelling of domestic pharmaceutical production.

In an intriguing way, these cultural anthropologists’ accounts—of either dismissal or acceptance of the dangers of fake drugs—draw heavily on a parallel conversation playing out across the realms of expert and popular public policy debate and within international activism. In this parallel policy conversation, we see legal activists and scholars such as K. M. Gopakumar and Sangeeta Shashikant (2010) argue, in similar terms to those of Sunder Rajan, that the politics of international anti-counterfeit pharma policing simply serves to protect big pharma’s lucrative markets. For these scholar-activists, the spectre of fake drugs is a pawn in a bigger chess game of international trade regulations and their role in determining who gets—and who is excluded from—access to lucrative pharmaceutical markets. The idea is of fake drugs as not a player but a play in the bigger game of foreclosing access to safe and affordable medicines for the world’s poor.

In contrast to Gopakumar and Sundar Rajan, but along the same lines as Peterson, Chorev’s account of pharmaceuticals within public policy (2019) understands fake drugs as a worrying handicap to the development of a local African industry. In short, most scholars have framed fake drugs in one of two ways: either a misleading distraction or an urgent problem to be eradicated.

Global health scholars have attended to fake drugs in different ways. Some have explored fake drugs in Africa as an example of how global intellectual property regimes have privileged certain interests at the expense of others (e.g., Cloatre 2016, Quet 2021). Others still, have situated fake drugs as central to a range of other practices and people that populate global health economies of goods and services (Kingori and Gerrets 2019; Kingori and Douglas Jones 2020). Within these accounts, we were surprised to watch the messiness of the fake qua fake fade from view.

We found the most open-ended, provocative, and generative approach to studying the fake in humanities scholarship—a field that excels in analysing questions of meaning. Some of this scholarship has been particularly inspiring for our analyses, as its authors also recognise the definitional quagmires in which claims to fake-ness thrive (Abbas 2008; Copeman 2018; Wong 2013). These scholars also are not burdened by infinite questions about the fundamental ontology of fakes. Instead, they have seized upon and explore the blurred, contested, and shifting boundaries that claim to separate authenticity from fake-ness. Their questioning of the very possibility of authenticity as part of a larger critique of the economic and cultural value of the fake is particularly noteworthy for us.

As much as we were stimulated by this work—in particular, by its ability to avoid instrumentalisation and to stay with the volatility of the fake rather than shy away from it—we realised that this critical thinking with the fake stopped short in the case of the medical fake. To engage critically with fake drugs, these scholars argue, is unacceptable because it requires a suspension of moral judgment (Abbas 2008; Copeman 2018; Wong 2013). The otherwise playful tone of this scholarship appeared spooked by the spectres of fake drugs in global health arenas and the immediacy of these objects’ presumed danger.

In contrast, in our work, we felt a need both for a conceptual framework and a methodological tool that would allow us not to attempt to resolve but to stay with the sheer strangeness of the fake drug in particular and the fake in general because we wanted to get to grips with the volatile, world-making power of the fake. We thought hard about Cori Hayden’s (2007) analyses of generic pharmaceuticals in Mexico, for instance, which show that, ‘accurate’ or not, claims about fakes and fake-ness can take on lives of their own. Hayden’s work matters to us because she takes claims about fake drugs seriously, albeit as claims . By showing how claims themselves have observable social, political, and economic effects, her analysis shows one way to move beyond seeing fake drugs simply as an effect of something else.

In our quest for a method and a conceptual framework that facilitated our engagement with the fake in all its unruliness, we drew on other ethnographers’ works, in particular, The Social Lives of Medicines (2003). In this work, Susan Reynolds Whyte, Sjaak van der Geest, and Anita Hardon set out a research programme that put at its centre accounts of people making, selling, buying, consuming, and, crucially, evaluating, medicines. We build on their approach because they help us stay with the problem of fake drugs as presenting a question or provocation made through people’s everyday practices, rather than as a self-evident problem in need of resolution or eradication.

In sum, by working through the complexity of the historical moment and the scholarship on fake drugs and fake-ness, we have been able to delineate a scholarly space into which we were compelled to introduce both a conceptual intervention and a method for thinking about fakes. Together, the latter form a way of thinking that helps us stay with the volatility of the subject matter and how it challenges both our own commonsensical critical instincts and the supposed danger of the fake. To overcome this challenge, we began to craft the concept of ‘fake-talk’ as a way to train our gaze on, first, the claims people make about fake-ness, and second, the work these claims do.

Fake-talk

Why fake-talk? We came to understand that there is a dominant cosmology—or discourse—that animates much of the global public health writing, both expert and popular, about fake drugs. Much of this writing reinforces the dominant position that the problem of fake drugs is self-evident and presents an urgent and life-threatening danger, while a secondary position disputes that such danger exists. We are trying to do something else altogether. We argue that the power and properties of fake-ness in the world can only be understood through identifying and investigating claims about fake-ness for what they do and where they go . In that sense, fake-talk is akin to rumour: the force of fake-talk requires neither evidence nor a directly attributable source. Our approach appreciates that the power of fake-talk resides not in its ‘truth’, but in the social work it does. Following on from this, we have attempted to train our collective critical gaze onto two very available objects of study: people making claims about fake drugs, and the observable effects of these claims. Studying fake-talk helps us identify both these claims and the work these claims do. By identifying and analysing episodes of fake-talk in different settings we are thereby able to take seriously and understand the power of fake drugs in the world.

Fake-talk is a powerful speech act. But in order to achieve such power, certain conditions have to be in place. Sometimes accusations of fake-talk fail to resonate with an audience; they fail to convince anyone of their broader significance. When fake-talk does gain momentum it tends to do so in three interconnected ways, which in turn lead to the three conceptual propositions that we put forward here. We first introduce these abstract conceptual propositions, then elaborate them below using ethnographic examples from this special section.

Fake-talk thrives on a lack of evidence

Fake-talk lacks evidence. And yet, this lack of evidence is not a ‘dead-end’; it is in it that much of its power resides. It makes fake-talk available to be mobilised by anyone about anything. As such, its trajectories are multiple, infinite, and arbitrary. It abandons one context and lands in another that may have no relationship with the one before. Fake-talk moves with ease across scale. Those who mobilise fake-talk reinvent it with each use. As a result, fake-talk lands and roots in ever-new grounds. It can only be understood and explained by the specificity of its contexts . In sum, fake-talk marries the arbitrary with the particular, and its significance and meaning for one context only become clear as we observe those who speak it and see its effects unfold. Normally, we might think that evidence is the anchor (or necessary precondition) of fake-talk. But what we are saying is the opposite: fake-talk is mobile because of the absence of evidence, which is the necessary precondition for fake-talk to take flight and travel in the first place.

Fake-talk imports urgency

Instead of evidence, fake-talk is propelled by urgency. Fake-talk animates ever-new contexts by conveying a viscerally felt urgency, and it changes the relationships governing these new contexts. Fake-talk creates a shared template for understanding a problem. It transforms contexts into recognisable patterns: the spreading of an imminent threat; a growing suspicion; distrust. Through this urgency, fake-talk can authorise calls for action and intervention. Fake-talk imports this urgency and danger from other contexts where they have gathered steam and from which they spill over. In this way, fake-talk is sticky. In carrying with it traces of the contexts through which it travels, it creates new connections across and between them . In other words, it brings together dispersed and previously unconnected worlds into new and intimate relations with each other.

Fake-talk is expressive

Exploiting the ability of fake-talk to bypass questions of evidence, to presume urgency, and to connect otherwise unrelated contexts, those who engage in fake-talk are able to say the unsayable. Fake-talk enables new forms of expressing pre-existing discomforts and anxieties and offers a new way to name or frame existing tensions, tensions that would otherwise seem unspeakable or insurmountable. Crucially, fake-talk thrives because calling something ‘fake’ can provide a solution to an otherwise puzzling or unresolvable problem. More than simply deflecting from discomfort, fake-talk thus appears to make intelligible what otherwise defies analysis or would upset a particular perceived (world) order. Despite—or perhaps because of—the lack of evidence needed to engage in fake-talk, and because of its register of moral and visceral urgency, fake-talk can bring certainty or resolution to the inexplicable or unbearable.

To summarise: as fake-talk flares up, it does so only through the particularity of a context. In the process, it changes that context by bringing it into contact with other contexts in which fake-talk’s urgency has already taken shape. These new and sometimes unlikely connections, then, need to be studied by suspending expectations of predictability. We use the examples of fake-talk in the following section of this paper to understand fake-talk’s unfettered mobility, to trace the importation of fake-talk’s urgency, and to trace fake-talk’s expressive power. What this means is that when we study fake drugs through the conceptual and methodological tool of fake-talk, we study not only medicines but the predicaments of our contemporary world.

Fake-talk in action

What does fake-talk look like in action? What, exactly, does it mean to ‘stay with’ the fake and all its volatility? In this final section, in order to answer these questions and put our propositions about fake-talk to work, we draw on the contributions to this special section, those by Rhoda Bandora, Edmore Chitukutuku, Sarah Hodges, Julia Hornberger, Keketso Peete, Christopher Sirrs, and Nishpriha Thakur—all members of the research collective for the project What’s at Stake in the Fake? ( https://www.fakedrugsproject.org/ ). Through close reading of this work, we show how our conceptual framework of fake-talk both emerges from the actuality of our field-, desk-, and screen-work and how fake-talk can function as a generative interpretive frame.

Starting with Christopher Sirrs’s contribution to this special section, he traces the series of terms that the World Health Organization (WHO) has employed to get at the ‘trouble with fake drugs’. Initially, the WHO set about managing drug standards, broadly referred to as ‘quality’, across pharmaceutical manufacturers. By the final decades of the twentieth century, alongside ‘quality’ appeared its other: ‘sub-standard’. However, the career of the concept of ‘sub-standard’ was soon overshadowed by that of the ‘counterfeit’. To cut a long story short, ‘counterfeit’ proved to be a lightning rod for controversy. In arriving at the term, the WHO was accused of complicity with, or ‘selling out’ to, Big Pharma. More recently, the WHO sought to contain the controversy and rehabilitate its severely damaged reputation by offering a seemingly all-inclusive term: ‘sub-standard/spurious/falsely-labelled/falsified/counterfeit (SSFFC)’.

Sirrs’s article goes beyond a mere survey of terms to show two things: first, these terms were not ‘just words’; but second, neither did they reflect seriously changing material realities regarding the quality, or lack thereof, of these drugs. Instead, his article shows how each of these terms was both produced by and served different actors and interests.

What happens when we bring our interpretive frame of fake-talk to bear on Sirrs’s findings? Several things. Sirrs resists going along with WHO’s efforts and their hope that by finding the right term it might be possible to capture an otherwise elusive reality: that of the fake. His focus on individual and institutional actors and their interests, served by successive ineffective campaigns that seek to police, ‘capture’, and ultimately resolve the problem of the ‘real fake’, also reveals home truths about evidence. Evidence is not only absent in the careers of these campaigns, but the absence of evidence in and of itself fuels the imaginaries that call for successive campaigns to ‘fight the fakes’. The logic goes like this: “Just because we haven’t found the fakes doesn’t mean they are not there. It means that the problem is far worse than we had even considered. Renewed attention is urgently required. Evidence or not”. The fact that these campaigns emanate from within the WHO imbues this sense of urgency with legitimacy, conveying the notion that there is a genuine threat to health. Our interpretive frame of fake-talk reveals that this urgency fuels fresh interventions. Indeed, Sirrs describes manifold interventions, including market raids, policing campaigns, drug confiscation, and the burning of drugs.

In her article, Rhoda Bandora tells the story of women’s experiences accessing feki contraceptives in Tanzania. ‘ Feki ’ is a colloquial Swahili term that bears the traces of the English word ‘fake’ and stands in contrast to the Swahili word ‘ bandia ’ used in formal public health discourse. The word feki, however, as used by the women studied, does not so much refer to the quality of the drugs as to the nature of social relationships and experiences through which women access contraceptives. Perhaps surprisingly, none of Bandora’s informants claimed that their contraceptives were feki because they fell pregnant. Instead, these women explained their concerns about feki contraceptives in terms of the drugs’ side effects, which ranged widely and wildly from backaches to social decay. These women linked said decay to a betrayal of the image and expectations of a good, child-bearing, halali (pure) Tanzanian woman. Bandora argues that by mobilising the term ‘ feki ’ these women created a bearable distance between themselves and immoral agents, by attributing moral decay to the drugs themselves. By thus harnessing the danger and power attributed to fake drugs, the women were able to make use of contraceptives ‘under the radar’ of moral policing.

Bandora’s article illustrates several aspects of how fake-talk works and what thinking with fake-talk allows for in an analysis. First, let us consider the matter of evidence. The underlying idea of fake-ness is that a fake drug does not work. In this case, the evidence of fake-ness would be that these women fell pregnant. However, these women’s accounts cast aside this causal chain. Thinking with fake-talk allows us to see that this absence of the standard role of evidence in the making of meaning opens up a space in which fake-ness shifts from indexing the inefficacious to feki indexing a social dynamic. Rather than falling pregnant, a living archive of rumours and whispered experiences about side effects is what renders drugs feki in these women’s everyday lives.

Second, Bandora’s account highlights how fake-talk is expressive. By talking about contraceptives as feki, these women simultaneously articulate their predicament while distancing themselves from the social taint of immorality. Declaring their experiences with contraception as feki allows these women to describe themselves as fertile and non-fertile at the same time. To discuss their own contraceptive use in terms of feki medication is thus both an expression and a resolution of the social tension that they are caught up in as part and parcel of controlling their own fertility.

Third, methodologically speaking, Bandora’s account shows the value in staying with the—often unexpected—work that the fake does in the stories that people tell. Rather than holding these accounts ransom to a search for ‘actual’ or expected evidence of fake-ness, in her research Bandora opens a window onto the breathtaking capaciousness of what fake-talk can create for its speakers.

In her article in this special section, Nishpriha Thakur describes how Indian pharmaceutical exporters have changed their practices in response to the emergence of a new drug security paradigm for governing pharmaceutical trade. This paradigm of drug security supplanted an earlier one of drug safety, transferring the locus of evidence from pharmacological analyses of manufactured drugs to manufacturers’ quality-assurance paperwork. Thakur shows how the dossier—a kind of passport for drugs; an electronic file of all the paperwork required for drugs to be traded—becomes the site where drugs’ fake-ness or authenticity is produced. In her study, Indian traders use the term ‘sub-legal’ to frame and negotiate their predicament. That is, they find themselves in a situation where it is nearly impossible to keep up with the ever-growing demands of drug security. Most of the traders struggle to produce—and indeed to fund—the exacting and very costly standards of paperwork demanded by international trade regulators. In this bureaucratic process, the importance of a drug’s pharmacological properties is eclipsed by the work of international lawyers who craft these highly specialist documents. In the paradigm of drug security, what is tested are the contents of the dossier rather than the contents of the drugs.

Thinking with fake-talk allows for a critical reading of drug security in the case of Thakur’s work; in particular, how it is fuelled by the standard media portrayal or policy assumption that institutionalised drug security can manage the potential risks posed by the spectre of the always already-suspect Indian pharmaceutical traders, and which positions these traders as the potential crooks paying bribes to bring their non-standard goods to market. In her article, Thakur stays with the traders’ use of the term ‘sub-legal’, not dismissing it as a cover-up or a confession. In so doing, fake-talk allows her to turn a critical gaze onto what drug security itself does: position itself as a way to manage an imagined global pharmaceutical supply chain that is out of control and awash with outlaws. Drug security is a regime whose raison d’être is to counter a perceived urgent, deadly threat to health, and this urgency transforms expectations of what constitutes evidence and what evidence must prove. Within the drug security paradigm, the dossier is freighted with the need to perform its evidence ever more robustly. Because of the nature of urgency, which is viscerally felt rather than actually known, drug security is characterised by a state of suspicion that even a perfect dossier fails to soothe. This urgency becomes self-perpetuating: it is both the cause and the effect of drug security. By thinking with fake-talk, we can see how apparently banal paperwork comes to constitute the quality of the drug, even as the paperwork cleaves said quality from the material properties of an individual tablet.

Keketso Peete’s article draws on a close reading of Twitter commentary during the initial months of global lockdowns in 2020. This commentary was characterised by uncertainty about the nature of the spread and potential deadliness of the then novel coronavirus. Peete explores Tanzanians’ claims and counter-claims about the true dangers presented by COVID-19, paying particular attention to the centrality of claims about so-called fake news. Many tweets seized upon the then-president of Tanzania and his dismissal of the global preoccupation with the pandemic. These tweets used the president’s position as fodder for their own expressions, even as the debate quickly moved beyond the views of the president himself. Through this account, Peete shows that calling something fake, perhaps counter-intuitively, does not dismiss it or reduce its significance. Rather, it heightens both its prominence and its power, as the debate carried on with ever more tweets and the platform’s users constantly reiterating their position. Even more, claims of fake-ness bestow a new valence, transforming one thing into something else: in this case, claims about the fake-ness of news on Twitter served as a field in which Tanzanians performed their postcolonial identities and national loyalties.

What analytical work does fake-talk do in Peete’s account? This early phase of the COVID-19 pandemic provided conditions in which we were all faced with making sense of the world in the absence of explanatory frameworks and their corollary guidance on what details were in fact evidence. Under these conditions, thinking with fake-talk allows us to see how evidence works—or doesn’t. Tweets that called COVID ‘fake’ or denied its very existence did two things. First, they made the object of the claim—the very nature of a new infectious disease—difficult for anyone truly to ‘know’. Although tweeted denials of COVID’s effects appeared to want to smother news deemed false (e.g., numbers of ill or dead, how one contracts the disease, and so forth), such ‘fake news!’ accusations served instead to call attention to and thereby amplify the force of these tweets. In addition, thinking with fake-talk helps us see the work that urgency does in Peete’s account. As these debates took place in the context of the early COVID-19 pandemic, people infused their utterances with the affect of an unfolding global public health crisis. In the febrile atmosphere of radical uncertainty about the nature of COVID-19, even those who were sceptical about the very idea of COVID were still able to mobilise its urgency to strengthen their pledge to a national mission.

Peete does not try to resolve these apparent contradictions. Together, the lack of evidence and the sense of urgency produce a formidable space for the pure performativity of fake-talk. Thinking with fake-talk allows Peete to attend to the expressions that emerge concerning both the Ujamaa ¹ of a non-aligned past and the populism of present-day Tanzania. This combination attempts to overcome the postcolonial predicament of maintaining national dignity and performing independence, whilst completely subject to powerful global forces.

Finally, the article by Julia Hornberger, Sarah Hodges, and Edmore Chitukutuku, recounts a fake food scandal that recently gripped South Africa as it appeared to many commentators to threaten to become a public health crisis. This scandal was narrated through mainstream and social media as a story of Asian and African immigrants selling poor-quality food in these small spaza shops typically run in South African townships. In response to the media outcry, these shops became the site of protest and, in some cases, of looting. The outcry caught the attention of the state authorities who responded swiftly and decisively, closing shops and deporting immigrants. Usually, township residents’ cries about criminal foreigners fail to move the state. In this case, however, food poisoning was fresh in the public imagination because of a recent deadly outbreak of listeriosis to which the state successfully and decisively responded by ordering widespread inspections of food production units. Through the shorthand of a call to public health, recently rehearsed through the listeriosis crisis, the state was able to overcome its usual torpor in the face of a popular outcry about spaza shops—an outcry they were better practised at dismissing as xenophobic.

In analysing the spaza shop furore, thinking with fake-talk allows Hornberger, Hodges, and Chitukutuku to bring various things to the fore. First, their analysis shows how persuasion-based performances on social media such as YouTube invited viewers to imagine evidence. These performances imbued the spectre of fake food with the arguably unconnected urgency of an imminent public health crisis. Thinking with fake-talk we can see how, by presenting fake food as part of a potential public health crisis, the videos make a further connection—that between a logic of public health and that of xenophobia. The article also demonstrates the power of fake-talk to move the unmovable: the state responded to the complaints of its poor. By attending closely to how the rhetoric of these videos works, we can see two ways in which, through fake-talk, a space opens up for the expression of a particularly South African predicament. That is to say, in South Africa today, democracy does not seem to have led to the promised social and economic liberation of the poor. Within this context, people who come from other countries are regularly scapegoated. It is against this background that analysis of fake-talk allows us to see the significance of decisive state action which, in the form of a flurry of public health inspections, resulted in a series of deportations. The account of fake-talk and the spaza shop began with worries about allegedly fake food, but its prosecution was borne by individuals of foreign origin. Through the analytical lens of fake-talk we come to appreciate how this apparent mismatch—between public health danger and immigration prosecution—in fact realised the very possibility of all too rare hopes of redress for protesters.

Conclusion

The point of our discussion of these examples above is to expand and deepen our understanding of fake-talk as concept and method. And to show how fake-talk works and moves without pre-existing fact or evidence, how it moves through the visceral power of invoking urgency, and how it provides a new language for expressing otherwise inexpressible predicaments and anxieties.

We have argued that fake-talk thrives in the absence of evidence. As Peete’s analysis of Twitter users’ commentaries debating the existence of COVID-19 showed us, these tweets thrived in an atmosphere of radical planetary uncertainty in which speculation, rather than hard evidence, served as the basis for action. In Thakur’s account of the sub-legal and the emergence of the drug security paradigm, the dossier displaced pharmacological testing as the gold standard for evidence and replaced it with a self-perpetuating proliferation of paperwork that itself constituted a disappearing horizon of evidence. We have also argued that fake-talk moves through the visceral power of invoking urgency, as seen in the South African fake food scandal. This showed how the memory and affect of a recent and deadly listeriosis outbreak crisis imbued claims about fake food with urgency, moving the state to act. Sirrs’s account similarly shows how the emergence of a drug security regime was mobilised through the urgency that came with an imagined battle against a vast criminal network. Finally, we have argued that fake-talk is able to express otherwise inexpressible predicaments and anxieties. This is exemplified in Bandora’s article, where, by calling contraceptives ‘ feki ’, women are able both to distance themselves from and bear the moral taint that they risk by managing their own fertility. Similarly, in Peete’s account, Tanzanians are able to perform—albeit momentarily—a postcolonial dignity that the current global dispensation otherwise denies.

Building on these insights, we tease out two additional dynamics that become apparent when we put these three aspects (evidence, urgency, expressiveness) of fake talk together: evidentiality and connectedness. In carrying out this collective research what we noticed is that while fake-talk clearly thrives on an absence of evidence, this absence did not remain a deficit. Instead, a lack of evidence became the opportunity for a lavish performance that suggests the existence of evidence. This is what we mean by ‘evidentiality’ (Hornberger, Hodges, and Chitukutuku, this special section). Such evidentiality is illustrated by the YouTube video performances in the South African fake food scandal, in Tanzanian women’s recitations of rumours about contraceptives’ side effects, and in the self-perpetuating digital paperwork of international pharmaceutical standard-making. Evidentiality is to be found in the distinct ecologies of utterances and evocations that are often dismissed—as in Peete’s account—as ‘fake news’. Thinking with fake-talk helps us demonstrate that even policymaking functions through innuendos and hints of danger rather than through unambiguous evidence, as in Sirrs’s account. What is important here is that fake-talk’s expressiveness dwells precisely across distinct media (such as rumours, tweets, viral videos, written dossiers, WHO policy documents), and can be apprehended through careful witnessing of performances of evidentiality. Fake-talk allows the observer not to dismiss or discount the role of these utterances, but to see them as productive stages through which people develop a language for speaking about the unspeakable.

Alongside evidentiality we noticed a second feature, which is the particular connective work that fake-talk can do. Apparently unconnected—if not antagonistic—contexts were being brought together by means of fake-talk. In the case of the fake food scandal, the memory of a public health crisis came to inform xenophobic sentiment and state action. Paying attention to the connective work that fake-talk does also helps us to see that the pathways of fake-talk are neither arbitrary nor predictable but are entirely contingent on the contexts through which they emerge. As fake-talk moves from one context to another, it brings traces of what came before and moves them onwards towards somewhere else. How might we characterise these patterns of movement? Patterns of fake-talk do not mimic the idea of a rational centre and its irrational margin. Fake-talk does not radiate out from a central command. Nor does it simply circulate in some wild, free-for-all. We have tried on for size, and discarded, a number of different terms in the hope of capturing the dynamic that may best define fake-talk: ‘rhizome’, ‘archipelago’, ‘constellation’. We have witnessed how fake-talk thrives by developing horizontal linkages with other nodal points of fake-talk. And it does so in a given context, one that allows it to become expressive in all its force.

The methodological implications of this dynamic are many. When we follow the careers of fake-talk from context to context and position fake-talk as our primary object of study, what emerges are the social and cultural worlds inhabited by scientists, customers, regulators, tweeters, and traders who traffic in and through fake-talk. Equipped with the analytical tool afforded by fake-talk we investigate the social worlds where claims to fake-ness originate and in which they may circulate. We then investigate the circulation of said claims and the new connections they forge, say, between skin-lightening creams or contraceptives and certain people, and back again. In turn, thinking with fake-talk allows us to observe the social, political, and economic effects that these claims produce and sustain. Methodologically, thinking with fake-talk helps us to show how fake-talk connects the otherwise unconnected, without us having to ascertain the ‘truth’ of the claim or the logic of the semiotic connection.

Fake-talk is a powerful concept for understanding the world. We also acknowledge the power of the fake, most apparent in the example of fake drugs, where the urgency and danger are most obvious and thereby knowable. So often claims about fake drugs get obscured by their own urgency, whereby a presumed danger to health overrides all other forms of insight. By mobilising the analytical lens or conceptual tool of fake-talk, we hope to rescue or rehabilitate the topic of fake drugs qua fake drugs and render it accessible to critical inquiry.

Authorship statement

The authors contributed equally to, and collaborated indistinguishably in, the writing of the paper.

Ethics statement

The research was conducted under the Wellcome Collaborative Award in the Humanities and Social Sciences ‘ What’s at Stake in the Fake? Indian Pharmaceuticals, African Markets and Global Health ’ (212584/A/18/Z and 212584/C/18/Z). The views expressed in the article are those of the authors.

Acknowledgements

The authors benefitted from interventions on earlier drafts of this article from Rhoda Bandora, Carlo Caduff, Rene Gerrets, Zoe Goodman, Ushehwedu Kufakurinani, Erin Martineau, Keketso Peete, Shalini Rudra, and Nishpriha Thakur. Erin Martineau’s editing made a good paper that much better. Kel Weinhold’s coaching helped us realise the power of our close collaboration as co-authors. This article also benefitted from comments received at the Culture Medicine Power work-in-progress seminar in July 2022 (Global Health and Social Medicine, King’s College London), at the Risky Hormones project meeting that took place in Berlin in May 2022, and at the ‘ What’s at Stake in the Fake? Indian Pharmaceuticals, African Markets and Global Health ’ workshop that took place in September 2022 at King’s College London. We also benefitted from out the two anonymous reviewers’ comments that challenged and encouraged in just the right measure. Finally, we are very grateful to Cristina Morenzo Lozano and Emma Fossey whose careful readings helped give the article greater clarity and polish.

About the authors

Julia Hornberger is Associate Professor in the Department of Anthropology at the University of the Witwatersrand, Johannesburg. Julia’s research sits at the intersection of the anthropology of policing and the anthropology of medicine. Her research asks questions about the often fraught relationship between security and health. She does so through ethnographies that move between South Africa and its global interlocutors. She is the author of Policing and Human Rights : The Meaning of Violence and Justice in the Everyday Policing of Johannesburg, and the co-editor (with M. Morelle and F. le Marcis) of Confinement, Punishment and Prisons in Africa .

Sarah Hodges is Professor of Global Health and Social Medicine at King’s College London. Sarah uses ethnography and historical records to ask: what are the everyday lives of public health measures in India? She is author of Contraception, Colonialism and Commerce: Birth Control in South India, 1920−1940 , editor of Reproductive Health in India: History, Politics, Controversies , and co-editor (with Mohan Rao) of Public Health and Private Wealth: Stem Cells, Surrogates and other Strategic Bodies .

References

Abbas, Ackbar. 2008. ‘Faking Globalization’. In Other Cities, Other Worlds: Urban Imaginaries in a Globalizing Age , edited by Andreas Huyssen, 243–64. Durham, NC: Duke University Press.

Abraham, John. 2010. ‘Pharmaceuticalization of Society in Context: Theoretical, Empirical and Health Dimensions’. Sociology 44 (4): 603–22. https:/doi.org/10.1177/0038038510369368 .

Bandora, Rhoda. 2023. ‘Fake-talk, Side Effects, and the Trouble with Hormonal Contraceptives among Women in Dar es Salaam’. This issue.

Baxerres Carine. 2014. ‘Faux médicaments, de quoi parle-t-on ? Contrefaçons, marché informel, qualité des médicaments... Réflexions à partir d'une étude anthropologique conduite au Bénin’. Bulletin de la société de pathologie exotique 107: 121–26. https://doi.org/10.1007/s13149-014-0354-9.

Baxerres Carine, 2015a. ‘Les “faux medicaments”: Analyse d’une notion ambigüe à partir d’une étude anthropologique au Bénin’. In Nouveaux enjeux éthiques autour du médicament en Afrique. Analyses en anthropologie, droit et santé publique , edited by Alice Desclaux and Mamadou Badji, 169–78. Dakar: L’Harmattan Sénégal.

Baxerres Carine. 2015b. ‘Contrefaçon pharmaceutique: la construction sociale d’un problème de santé publique’. In Anthropologie du médicament au Sud. La pharmaceuticalisation à ses marges , edited by Alice Desclaux and Marc Egrot, 129–46. Paris: L’Harmattan - Editions de l’IRD, Collections Anthropologies et Médecines.

Calhoun, Craig. 2004. ‘A World of Emergencies: Fear, Intervention, and the Limits of Cosmopolitan Order’. Canadian Review of Sociology 41 (1): 373–95. https://doi.org/10.1111/j.1755-618X.2004.tb00783.x .

Chorev, Nitsan. 2019. Give and Take: Developmental Foreign Aid and the Pharmaceutical Industry in East Africa . Princeton, NJ: Princeton University Press.

Cloatre, Emilie. 2016. ‘Fluid Legal Labels and the Circulation of Socio-Technical Objects: The Multiple Lives of “Fake” Medicine’. In Exploring the Legal in Socio-Legal Studies , edited by David Cowan and Daniel Wincott, 97–114. London: Palgrave Macmillan.

Copeman, Jacob. 2018. ‘Exposing Fakes’. In Fake : Anthropological Keywords , edited by Jacob Copeman and Giovanni Da Col, 63–90. Chicago: HAU Books.

Deleuze, Gilles, and Felix Guattari. 1987. A Thousand Plateaus: Capitalism and Schizophrenia . Capitalism and Schizophrenia. Minneapolis, MN: University of Minnesota Press.

Dumit, Joseph. 2012. Drugs for Life: How Pharmaceutical Companies Define our Health . Durham, NC: Duke University Press.

Gopakumar, K. M., and Sangeeta Shashikant. 2010. Unpacking the Issue of Counterfeit Medicine . Penang: Third World Network.

Hayden, Cori. 2007. ‘A Generic Solution? Pharmaceuticals and the Politics of the Similar in Mexico’. Current Anthropology 48 (4): 475–95. https://doi.org/10.1086/518301 .

Hodges, Sarah. 2019. ‘The Case of the “Spurious Drugs Kingpin”: Shifting Pills in Chennai, India’. Critical Public Health 29 (4): 473–83. https://doi.org/10.1080/09581596.2019.1593948

Hodges, Sarah and Emma Garnett. 2020. ‘The Ghost in the Data: Evidence Gaps and the Problem of Fake Drugs in Global Health Research’. Global Public Health 15 (8): 1103–18. https://doi.org/10.1080/17441692.2020.1744678 .

Hornberger 2018. ‘From Drug Safety to Drug Security: A Contemporary Shift in the Policing of Health’. Medical Anthropology Quarterly 32 (3): 365–83. https://doi.org/1 0.1111/maq.12432 .

Hornberger, Julia. 2019. Populism and the Circulation of Fake Goods/Medication . Presentation, Michigan University, Ann Arbor, MI, 17 November 2019.

Hornberger, Julia, Sarah Hodges and Edmore Chitukutuku. 2023. ‘Fake-talk and the Spaza Shop: A Fake Food Furore and the Spectre of Public Health Emergencies in South Africa’. This issue.

IMPACT. 2011. Facts, Activities, Documents Developed by the Assembly of the Working Groups 2006–2010 . Rome: Agenzi Italiana del Farmaco.

Kingori, Patricia, and Rachel Douglas Jones. 2020. ‘Revelation or Confirmation? The “Fake Probe” in Global Health’. Medicine Anthropology Theory 7 (2): 214−29. https://doi.org/10.17157/mat.7.2.776

Mayne, Ruth. 2005. Regionalism, Bilateralism, and ‘TRIPS Plus’ Agreements: The Threat to Developing Countries . New York, NY: UNDP.

Pang, Laikwan. 2008. ‘“China Who Makes and Fakes’: A Semiotics of the Counterfeit’. Theory, Culture & Society 25 (6): 117–40. https://doi.org/10.1177/0263276408095547 .

Peete, Keketso. 2023. ‘Fake news matters: Digital media and fake-talk around COVID-19 in Tanzania’. This issue.

Peterson, Kristin. 2014. Speculative Markets. Drug Circuits and Derivative Life in Nigeria . Durham, NC: Duke University Press.

Porter, Roy. 1999. The Greatest Benefit to Mankind: A Medical History of Humanity. London: Harper Collins.

Quet, Mathieu. 2017. ‘Values in Motion: Anti-Counterfeiting Measures and the Securitization of Pharmaceutical Flows’. Journal of Cultural Economy 10 (2): 150–62. https://doi.org/10.1080/17530350.2016.1258001 .

Sirrs, Christopher. 2023. ‘Fluid “Fakes”, Contested “Counterfeits”: The World Health Organisation’s Engagement with ‘Fake’ Drugs, 1948–2017’. This issue.

Sunder Rajan, Kaushik. 2017. Pharmocracy: Value, Politics, and Knowledge in Global Biomedicine . Experimental Futures. Durham, NC: Duke University Press.

Tattersall, Ian, and Peter Névraumont. 2018. Hoax: A History of Deception: 5000 Years of Fakes, Forgeries and Fallacies . New York, NY: Hachette Book Group.

Thakur, Nishpriha. 2023. ‘Sub-standard or sub-legal? Distribution, pharma dossiers, and fake-talk in India’. This issue.

Whyte, Susan Reynolds, Sjaak van der Geest, and Anita Hardon. 2003. The Social Lives of Medicines . Cambridge: Cambridge University Press.

Wong, Winnie Wan Yin. 2013. Van Gogh on Demand: China and the Readymade . Chicago, IL: University of Chicago Press.

Meaning ‘familyhood’ in Kiswahili, Ujamaa was a socialist government policy instituted in 1967 that was based on the idea that Tanzania’s development could best be attained if the country were self-reliant. ↩︎

Meaning ‘familyhood’ in Kiswahili, Ujamaa was a socialist government policy instituted in 1967 that was based on the idea that Tanzania’s development could best be attained if the country were self-reliant. ↩︎