Stefan Ecks

Pharmaceutical Citizenship: Antidepressant Marketing and the Promise of Demarginalization in India

Among practitioners of biomedicine, to speak of people as ‘marginalized’ often amounts to saying that they do not have access to medical substances. Thus conceived, the best way to remove marginality seems to be to give medicines to those deprived of them. The peculiar relationship between marginality and pharmaceuticals is especially poignant in the case of antidepressant drugs, as these drugs appear to bring the patient ‘back into society’, but not any society, but middle-class consumer society. What is now special about antidepressants is that there is nothing special about them: antidepressants are like consumer items among thousands of other consumer items. This paper explores the relations between medicines and marginality with reference to the marketing of antidepressant drugs in Kolkata (Calcutta), India. Drawing on ethnographic fieldwork in the Kolkata metropolitan area from July 1999 to December 2000 and in August/September 2003, this paper examines how people with depression are constituted as ‘marginal’ in the sense of ‘being deprived of medication’, and how the biomedical promise of an effective pharmacological treatment becomes a promise of ‘pharmaceutical citizenship’. In view of Bengali notions of mental health as a state of detachment, the paper asks if pharmacological demarginalization holds the same promise in the Indian context that it holds in the West.

Global Pharmaceutical Markets and Corporate Citizenship: The Case of Novartis’ Anti-cancer Drug Glivec

This paper analyses a remarkable transformation of global capitalism in recent years: that corporations claim to be ‘good citizens’ and are driven by higher aspirations than profits alone. It focuses on the lawsuit brought by the drug company Novartis against the Indian government over the patent for the anti-cancer drug Glivec. Novartis’ attack on Indian patent law caused an international outcry. Opponents of Novartis argued that the company was trying to destroy essential provisions in the Indian law that keep drugs affordable even after the country signed up to the World Trade Organizations agreement on Trade-Related Intellectual Property Rights (TRIPS). With reference to ‘the constitutional obligation of providing good health care to its citizens’, the High Court in Chennai, India, dismissed Novartis’ challenge in August 2007. While health activists celebrated the courts decision as a victory for anti-corporate citizens, this article argues that Novartis won a more important battle elsewhere: to protect its profits in European and North American markets. The article shows how claims to ‘citizenship’ were mobilized by both anti-Novartis and pro-Novartis groups, and how Novartis’ global corporate citizenship programme succeeded even when it seemed to fail.

The Ills of Marginality: New Perspectives on Health in South Asia

Social marginality and ill health can form an unholy dyad: firstly, groups who suffer from chronic or infectious diseases often find themselves pushed to the margins. Secondly, people who are already on the edge of society tend to suffer more from illness than those at the centre. In development discourse, marginal people are defined as those who are ‘not yet’ on the same level as the developed mainstream and are in urgent need of aid from the centre. The papers in this special issue take a different approach by insisting that marginality is a radically relational concept: the centre and its margins constitute each other, and the boundaries between them are constantly shifting. The papers show that there are many types of marginality (based on geography, class, caste, sex/gender, ethnicity, etc.), and that each of them has different effects on the health of a particular group. Yet instead of speaking of a plurality of unrelated ‘group identities’, marginality preserves a sharp sense of unequal power relations between groups. The specific ethnographic contribution to the study of marginality comes from its attention to the point of view of marginal people. This is of critical importance since marginality puts health most under stress when it is clearly and steadily perceived in everyday life. This, in turn, makes it possible to show that living on the margins is not always and everywhere bad for health. While all of the papers present South Asian case studies, the insights and questions are relevant for the study of the ills of marginality in a global perspective.

Bodily sovereignty as political sovereignty: ‘self‐care’ in Kolkata, India

This paper explores the potentials of applying Michel Foucaults notion of ‘self‐care’ to issues in medical anthropology. While Foucaults writings on regimes of power/knowledge have had an enormous influence on medical anthropologists, his late works on the ethics of the self have not yet received much attention. This paper discusses Foucaults notion of self‐care in relation to Ayurvedic interpretations of digestion in Kolkata (formerly Calcutta, India). In Kolkata, it is a widely held belief that attentive care of the self, and especially for the stomach, can set a person free from dependencies. Yet at the same time, ‘modern’ people are seen as unable to live up to the ethics of self‐care. The parallel between bodily sovereignty and cultural/political sovereignty produces a discourse on ‘lack of self‐control’ as one of the main reasons for continuing dependency in all spheres of life. How does Foucaults late work help to conceptualize these findings?

“We Always Live in Fear”: Antidepressant Prescriptions by Unlicensed Doctors in India

In India, psychopharmaceuticals have seeped deep into both formal and informal pharmaceutical markets, and unlicensed “quack” doctors have become ready prescribers of psychotropics. These ethnographic insights trouble policies that aim at closing the treatment gap for psychiatric medications by “task shifting” to low-skilled health workers as if medications were exclusively available by prescription from public sector psychiatrists. This article describes what these doctors, known as rural medical practitioners (RMPs), know about psychotropics and how they use them in everyday practice. Unlicensed doctors learn about psychopharmaceuticals through exchanges with licensed doctors, through visits by drug companies’ sales representatives, and through prescriptions brought by patients. Although the RMPs exist outside the margins of legitimacy, they are constrained by a web of relations with patients, licensed doctors, pharmacists, drug wholesalers, and government agents. The RMPs do not only prescribe but also dispense, which leads to conflicts with licensed medicine sellers. They “always live in fear” both because they are illegal prescribers and because they are illegal sellers of medications. The article shows that any form of strategic ignorance among policy makers about the local importance of informal practitioners in India can only lead to lopsided interventions.

Anthropological engagements with modern psychotropy.

Whether real or imagined, our world today seems saturated with psychiatric compounds. Stanislaw Lem’s dark (and hilarious) opening pages in The Futurological Congress anticipate a world where drugs and their byproducts are literally in the water we drink. In Lem’s vision designer drugs with neurological efficacy— drugs that psychiatrists and the pharmaceutical industry call ‘‘psychotropics’’—are pumped into the water supply to subdue the unruly masses of an overpopulated world. His science fiction creates a time and place where innocent people are ‘‘psychotroped,’’ induced into states of undirected joy and beatitude by drinking tap water. People can be also ‘‘troped’’ (p. 127) in the opposite direction, into darker moods and behaviors, by replacing an amino group with a hydroxyl, creating drugs like Antagonil, Sadistizine, and Furiol (p. 15). In our current world, especially in the United States, we have entered into the era of science-fiction-meets-reality as people begin to be exposed to psychotropics on a daily basis in their urban water supplies. Psychiatric medications and other psychoactive compounds, such as prescription pain medications [e.g., the opiates, such as Vicodin (hydrocodone bitartrate and acetaminophen)] and sedatives as well

Commentary: Ethnographic critiques of global mental health:

Global Mental Health (GMH) is a young field of research and policy, no older than 25 years. The current meaning of ‘‘global mental health’’ is even younger: it was only in the early 2000s that global mental health ceased to mean a population’s overall (‘‘global’’) stress level, but a programme of ideas and interventions for mental health for all (Cohen, Patel, & Minas, 2014). The label ‘‘global mental health’’ was slow to gain traction, even in the key publications that signpost the development of the movement. Neither the World Development Report (World Bank, 1993), the book on World Mental Health (Desjarlais, Eisenberg, Good, & Kleinman, 1995), nor the World Health Report 2001 (World Health Organization [WHO], 2001) contain the phrase ‘‘global mental health.’’ Only from 2001 onwards does ‘‘world’’ mental health turn into ‘‘global’’ mental health (e.g., in the WHO Mental Health Gap Action Programme [2008]). It helps to distinguish Global Mental Health—in capital letters and with the abbreviation ‘‘GMH’’—from broader issues in transcultural psychiatry and the globalization of Western psychiatry. GMH is one moment in a long series of globalization processes in psychiatry: an important moment, but one among many moments. GMH was formed when a set of disparate fields and concerns were assembled in a new way. Psychiatric epidemiology rests on the symptoms-based approach pioneered by the DSM-III in the 1970s. Calculations of the impacts of mental disorders on national economies go back to the introduction of disability-adjusted life years (DALYs) in the 1990s, when the ‘‘global burden’’ of mental disorders such as depression got specific price tags. The analysis of health infrastructures and of the availability of competent doctors and nurses has been a staple of public health research since its beginnings. The spectrum of therapies deemed to be based on ‘‘best evidence’’ by advocates of GMH had all been established before the 1990s, especially psychopharmaceutical treatments. Another pillar of GMH, the drive to educate the public and to minimize the stigmatization of mental

‘It just opens up their world’: autism, empathy, and the therapeutic effects of equine interactions

ABSTRACT Experiences of autism-spectrum disorder are now increasingly studied by social scientists. Human–animal relations have also become a major focus of social inquiry in recent years. Examining horse-assisted therapy for autistic spectrum disorders, this is the first paper that brings these fields together. Drawing on participant observation and interviews at a UK horse therapy Centre, this article examines how staff and the parents of riders account for the successes and limitations of equine therapy. To the respondents, horses ‘open up’ autistic children and make possible interactions that seemed impossible before. Horses were regarded as facilitating the emergence of apparently social behaviours, which included eye contact, pointing, and speech. Three key explanations emerged for therapeutic success: the sensorial, embodied experience of riding the horse; the specific movements and rhythms of the horse; and, the ‘personality’ of the horse. Equine therapy can be regarded as enabling a form of multispecies intersubjectivity, with the resonance between rider and horse seeming to make possible a new attunement between humans. Practices of equine therapy, and perceptions of its efficacy, serve in turn to attune social scientists to a version of empathy constituted through lively and sensorial interactions, as opposed to one that is restricted to particular kinds of humans.

Disentangling Family Life and Hair Pulling: Trichotillomania and Relatedness

ABSTRACT Trichotillomania (hair pulling) remains a relatively unknown form of body-focused repetitive behavior (BFRB). Sufferers tend to conceal both the action and its effects from others because of stigmatization, which is strong in both public and domestic spheres. Negative responses from close family members can add significantly to the suffering. Based on fieldwork in the United Kingdom and United States, we explore how hair pulling troubles ties even among close family members. We show why ethnographic methods reveal impacts of hair pulling that structured assessments do not yet capture and argue for a more nuanced study of BFRBs through anthropologies of relatedness.

The Public and Private Lives of Psychopharmaceuticals in the Global South

The chapter focuses on the global spread of psychopharmaceuticals, discussing how in 1990s psychopharmaceuticals were cast as heralding a new era of treating mental ills. Yet this hope, or hype, started to wane in the 2000s, and even large pharmaceutical companies are now withdrawing from this segment. Doubt about psychopharmaceuticals has even gained ground in the more recent policies of the World Health Organisation, which has moved from advocating drugs as the best first-line treatment to a greater emphasis on non-pharmacological therapies.The “public lives” of drugs that are captured by WHO treatment gap calculations are shown to be cut off from the “private lives” of psychopharmaceuticals in the prescriptions of nonspecialists in the private market. Drugs are circulating far more widely than is known, and the influence of manufacturers onto prescription patterns is far stronger than is assumed.