If biomedicine has a utopia it is the “magic bullet”: one specific drug that goes into the human body and destroys a pathogen without side effects to the host organism. In this model, symptoms occur, the patient recognizes the symptoms, builds a theory about causes, and then seeks medical help. The doctor diagnoses the true cause of the symptoms and prescribes an appropriate drug. And the drug’s active ingredient cures the disease.
In anthropology, we usually use the term magic bullet when speaking critically of biomedicine’s *reductionism,* challenging the model’s linearity and lack of cultural context. In our collaborative study on pharmaceutical supplies in India and Nepal, we tried to work with the concrete materiality of the drugs rather than against it. To do so, we inverted biomedicine’s magic bullet model. We looked first at what drugs were available and circulating in a local market, instead of starting with an epidemiology or an assessment of *needs.* That is, we started with the question of what drugs are actually prescribed, and in what quantity. From there, we asked the routine questions about health-seeking, but in reverse: How do drugs change diagnostics? How do diagnostics change ideas of illness causation?
In the larger project, we followed three drugs: rifampicin (treats TB), oxytocin (augments uterine contractions during labor), and fluoxetine (Prozac, the first *new generation* antidepressant). We traced these drugs through manufacturing, production, distribution, prescription, consumption, as well as through national and international regulation; and explored how diverse actors form networks, how power and money are distributed, and how asymmetries affect treatment outcomes. Following drugs around made us talk to people who are rarely, if ever, studied in detail such as drug wholesalers or carrying-and-forwarding agents.
In 2007, there were about 9.2 million TB patients globally and 2 million of them lived in India. From the anti-TB drugs, we chose Rifampicin because it is an essential component of every first-line treatment regimen. Most existing social science research on TB focuses either on community perceptions of TB, with *stigma* being identified as the main barrier to seeking help; or at people’s experiences with public sector treatments, especially their bad experience with the World Health Organization-sponsored approach called DOTS (Directly Observed Therapy, Short Course). But a lot gets overlooked when only patients and DOTS are studied. It is crucial to realize that 74% of all anti-TB drugs in India are prescribed and sold in the private sector, outside public programs. This paper is about Lupin Ltd., India’s leading manufacturer of anti-TB drugs. It shows how medical representatives are trying to convince private biomedical doctors to prescribe Lupin drugs to TB patients.
The fluidity of roles of medical representatives/social workers is interesting, but in the end, the representatives are proud that the patients demand that doctors prescribe the brand drug. Treatment is tied to brand loyalty. What are some of the limits of the market-based approach that you document?
Michael M. J. Fischer
Medical representatives work in-between different levels, the micro (neighborhoods) and the macro (e.g, the domestic drug market; changes forced on Indian patent laws by joining the World Trade Organization). Could you say more about how TB treatment fits within these registers? I would also be interested in what do people think is the prevalence or incidence of multi-drug resistant TB? Why isn’t there a focus on DOTS-Plus?
I have a few points and a question. You mentioned that magic bullets are specific, quick, and without side effects, but they are also simple and cheap. My guess on why Lupin collaborates with WHO in continuously updating and recalibrating anti-TB regimens: doctors tend to see diseases that are widespread in a society as uninteresting or even boring. In India, TB is so widespread that it becomes almost banal. In order to make disease interesting to the prescribers in private practice, medical representatives have to show to them how treating it can be a “science.” A question: What is at stake in showing discrepancies between statistics compiled by different agencies?
Michael A. Whyte
You raise the question about the lack of regulation for anti-TB drugs and so many other kinds of drugs. In Uganda, antiretroviral drugs (ARVs) are still pretty well controlled. You don’t see them on the informal market or being shared. Could you compare a little bit the different regulatory situations for ARVs versus the anti-TB drugs in India?
Regarding the limits of the market-based solutions: I am not advocating that the market is better in health delivery, not at all. Rather, I am arguing that there is no point in ignoring the existence of a huge private market for anti-TB treatments in India. It’s not going to go away just because WHO claims that there is “one hundred percent coverage” through the public sector DOTS centers. It is also clearly an illusion to think that public sector provisions can be successfully run in a vacuum, as if the sheer size and force of the private market had no influence on services like DOTS.
DOTS Plus just started in India, but estimates on multi-drug resistant TB are wildly diverse and there are no reliable statistics available. Whatever Lupin’s medical representatives say about the rise of MDR-TB as an outcome of DOTS failures, this must be seen as part of their commercial sales pitch. As for the MRs straddling both macro and micro levels: I would say that the MRs are more or less confined to the micro level, to dealing directly with their clients, doctors in private practice. The macro level of patent regimes and larger transformations of the Indian drugs market, this is all done by the company’s headquarters. In our research, we found that MRs, doctors, and people in drug retail were generally unaware of changes in patents and intellectual property regimes, even though these changes would directly impact their day-to-day work.
On magic bullets. We have these beautifully effective drugs against TB and people in the medical activist community say that there is no excuse for not eradicating the disease, only a lack of political will. Yet others argue that health systems must be strengthened in order to stem a one-sided pharmaceuticalization of public health. As for statistics, different agencies have different agendas. The WHO tends to underestimate what is happening in the private sector, whereas the TB Alliance (which has major drug corporations among its stakeholders) is more attuned to the private circulation of anti-TB drugs and this is reflected in their statistics.
Yes, diseases become *boring*, but not only to doctors. In fact, medical representatives specialized in anti-TB drugs sometimes sound like they are *bored* with their “archaic” products. One could take this idea further and question the routinization and boringness and hence neglect within public DOTS programs.
I think that antiretroviral drugs are the *exception* to a burgeoning and relatively unregulated drug market in India. Anti-tuberculars are like most other drugs in use in India. It’s arguably a case of *AIDS exceptionalism* and we should explore further the reasons for this.
I am intrigued by the sociality of the medical representatives. Could you theorize this with the way that medical representatives describe themselves as *social workers*? Is there not a moral economy at work here that is not reducible to the market?
You are looking at the role of marketing and profit-making in the health sector. The social ethos of medical representatives is interesting, but I would say, don’t be fooled—it is about market share and branding. There are no marketers who don’t appeal to the sociality of their customer base. For me, the other part of the story is the most fascinating: the interest in the lack of compliance to WHO-recommended treatment regimes among practitioners. Their individual-focused practice reminds me of Ayurvedic doctors. WHO’s idea that uniformity of practice among doctors should be expected is astounding. There’s no uniformity anywhere. And, if TB has been eradicated in other places, it was through improving standards of living rather than biomedical treatments.
Joseph J. Amon
More on the magic bullet: By focusing on medical representatives and their ethos, you were transferring the concept of the magic bullet to an approach, as opposed to just a drug. DOTS is a program built around the magic bullet rifampicin but the program itself is seen as a kind of magic bullet by its supporters. The irony is, of course, that these supposed magic bullet programs are so complex to prove that they can never reach the idealized straightforwardness of molecules. Also, at a macro level, WHO always needs to define targets to measure if an intervention is successful or not. In the case of DOTS, they define *100% coverage* of the Indian population as an all-round success; even if the real effects of DOTS are not captured.
Michael A. Whyte
Who are these medical representatives? Who are they at home? What is their gender, education? If market share is the key, what is it like to be pushing a low-market share brand? Is that like being part of a low caste? You’re looking at medical representatives from a top pharmaceutical company. How on earth does a new company break into the (free?) market in a system like this?