Pharmaceuticalization: AIDS Treatment and Global Health Politics
Biehl, João, Anthropological Quarterly
This article examines the political economy of pharmaceuticals that lies behind global AIDS treatment initiatives, revealing the possibilities and inequalities that come with a magic bullet approach to health care. It tells how Brazil, against all odds, became the first developing country to universalize access to antiretroviral drugs-a breakthrough made possible by an unexpected alliance of activists, government reformers, development agencies, and the pharmaceutical industry. The article moves between a social analysis of the institutional practices shaping the Brazilian response to AIDS and the stories and lives of people affected by it. It draws from interviews with activists, policy makers, and corporate actors and from longitudinal ethnographic work among grassroots AIDS care services.
Pharmaceutical innovations allow unlikely coalitions that both expose the inadequacies of reigning public health paradigms and act to reform, if to a limited extent, global values and mechanisms (of drug pricing and of types of medical and philanthropic interventions, for example). Treatment rollouts are matters of intense negotiation; their local realizations are shaped by contingency and uncertainty. Such realizations encode diverse economic and political interests, as well as the needs and desires of citizens. These therapeutic coalitions also expose the deficiencies of national and local infrastructures and consolidate novel state-civil society relations.
A pharmaceutically-centered model of public health has emerged as a byproduct of AIDS treatment scale-up and the sustainability of the Brazilian AIDS policy has to be constantly renegotiated in light of global drug markets. A multitude of networks and variations in AIDS care have emerged on-the-ground, and the article explores why AIDS treatment has been so difficult to put into practice among poor Brazilians, who are often stigmatized as noncompliant or untreatable, becoming invisible to the public. Poor AIDS patients live in a state of flux, simultaneously acknowledging and disguising their condition while they participate in local economies of salvation. At both the macro and micro levels, we see a state of triage and a politics of survival crystallizing. [Keywords: AIDS Treatment; Global Health; Pharmaceuticalization; Market-Based Biopolitics; Contemporary Brazil; Political Subjectivity]
The Right to a Nonprojected Future
In his book A Bias for Hope, economist Albert O. Hirschman challenges social scientists to move beyond categorical prejudgments, beyond the sole search for general laws and orderly sequences of what is required for wider social and political transformation. Having in mind the Latin American countries in which he worked (including Brazil), Hirschman challenges us, instead, to engage the unexpected. The study of how beliefs, attitudes, and values are refashioned and molded by "more or less accidentally undertaken practices," Hirschman argues, "widens the limits of what is or is perceived to be possible, be it at the cost of lowering our ability, real or imaginary, to discern the probable." 1 At stake is helping " to defend the right to a nonprojected future as one of the truly inalienable rights of every person and nation; and to set the stage for conceptions of change to which the inventiveness of history and a 'passion for the possible' are admitted as vital actors." 2
This article addresses the crucial question of what happens when such luminous prospects of social science are politically and technologically operationalized. Against all odds, Brazil invented a public way of treating AIDS.3 In 1996, it became the first developing country to adopt an official policy that provided universal access to antiretroviral drugs (ARVs), about five years before global policy discussions moved from a framework that focused solely on prevention to one that incorporated universal treatment. About 200,000 Brazilians are currently taking ARVs that are paid for by the government, and this policy is widely touted as a model for stemming the AIDS crisis in the developing world. …