When People Come First: Anthropology & Social Innovation in Global Health, João Biehl & Adriana Petryna (Eds.) Durham, NC: Duke University Press.
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Stefan Ecks & Ian Harper*
"There is No Regulation, Actually":
The Private Market for Anti-TB Drugs in India
*This paper emerged from the collaborative research project Tracing Pharmaceuticals in South Asia (2006-2009) that was jointly funded by the Economic and Social Research Council and the Department for International Development (RES-167-25-0110). The project team comprised: Soumita Basu, Gitanjali Priti Bhatia, Samita Bhattarai, Petra Brhlikova, Erin Court, Abhijit Das, Stefan Ecks, Ian Harper, Patricia Jeffery, Roger Jeffery, Rachel Manners, Allyson Pollock, Santhosh M.R., Nabin Rawal, Liz Richardson, and Madhusudhan Subedi. Martin Chautari (Kathmandu) and the Centre for Health and Social Justice (New Delhi) provided resources drawn upon in writing this paper. Neither ESRC nor DFID is responsible for views advanced here. We would also like to thank Amy Davies and Reena Ricks for sharing their Edinburgh MSc dissertations on public-private mixes with us.
Ten years ago, Paul Farmer called tuberculosis the "forgotten plague" (Farmer 2000: 185). While millions of people were dying every year of TB, the disease had become invisible for people living in rich countries. TB used to be at the forefront of public interest when it was rampant in the richer industrialized countries. But thanks to better nutrition, healthier living conditions, and more effective drugs, TB "ceased to bother the wealthy" (2000: 185). Against this forgetfulness, Farmer urged anthropologists to listen to the voices of the poor and to record their stories of deprivation and discrimination. But he also said that ethnography was insufficient to grapple with the problem. A comprehensive perspective on tuberculosis "must link ethnography to political economy and ask how large-scale social forces become manifest in the morbidity of unequally positioned individuals in increasingly interconnected populations" (2000: 197). Ethnographers could touch on "structural violence," but were unable to fully analyze it with their own methods.
Since the WHO declaration of TB as a global emergency in 1993, the fight against tuberculosis has received far more attention than previously, and even pessimists would now find it difficult to call TB a "neglected" disease. Several global initiatives have emerged to bring effective anti-TB drugs to even the world's poorest regions. For example, the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) has distributed US$19.3 billion to 572 programs in 144 countries (Global Fund 2010) since its 2
foundation in 2002. The WHO's push to spread directly observed treatment, shortcourse (DOTS) across all countries through their national TB control programs was also of great importance. DOTS aims to detect all TB cases through sputum microscopy and to enroll all patients into a treatment regime lasting six to eight months. DOTS has had many successes, and the global number of cases per capita has been falling by about 1% per year since 2004. However, the total number of cases is still growing due to overall population growth (WHO 2009: 1).
More awareness of the limits of this approach has led to the expansion of DOTS from 2005. The "Stop TB Strategy" (WHO 2010) contains six components: 1) expand and enhance DOTS; 2) focus on the poorest people, on HIV-co-morbidity, and on multi-drug resistant TB (MDR-TB); 3) strengthen primary health care; 4) engage all care providers; 5) empower people with TB; 6) promote research into new diagnostics, drugs, and vaccines. The strategy to "engage all care providers" entails plans to involve an array of voluntary, corporate, and private providers and to extend collaborations in "PublicPrivate Mixes (PPM)" (WHO 2009:...
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