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Interrogating the Hegemony of Biomedicine

Pharmocracy: Value, Politics and Knowledge in Global Biomedicine by Kaushik Sunder Rajan, Hyderabad: Orient Blackswan, 2017; pp 328 , 1,095.


Pharmocracy: Value, Politics and Knowledge in Global Biomedicine confronts the relationships between power and global biomedical regimes squarely. In the process, it brings to the forefront the political economy of global production, distribution and consumption of biomedical drugs in the 21st century. Its principal problematic is to understand, as the author points out at the beginning, global therapeutic regimes within a democratic political system, however contingent the site of that democracy might appear. In effect, therefore, it interrogates the manifestly powerful influence of the global biomedical behemoths that operate within the global South, and particularly in India. The problematic is an enduring one: ever since the Trade-Related Aspects of Intellectual Property Rights (TRIPS) agreement (2005) in deference to the World Trade Organization’s (WTO) recommendation, the landscape of the Indian pharmaceutical industry and market has transformed entirely, with patent laws being tightened so as to make any informal transfer of technology impossible.

Global Biomedicine

The TRIPS agreement has been studied and critiqued, and its consequences for the Indian domestic pharmaceutical industry has not been as bleak as had been prophesied at the outset. This is principally because the domestic pharmaceutical industry has shifted to the bulk production of generic medicines that do not require the protection of intellectual property rights in the form of patents on new therapies. However, although the industry itself has burgeoned and is now the third largest in the world in volume, the promises of greater innovation, foreign investment in manufacture (rather than marketing), and the greater good of public health, after the implementation of the TRIPS agreement have not quite materialised, the last having sounded hollow even at the outset. Sunder Rajan’s premise in this authoritative and yet moving book is to move beyond economic and “cynical” (p 7) accounts of the power of global biomedical companies and instead, to focus on the processes by which they have secured hegemony over the political economy.

This is where this book uniquely differs from others on the theme; it posits that this hegemony has allowed health “to be appropriated by the logics of capital … through the regimes of governance” (p 7) and despite resistances, is incorporated into “emergent forms of experimentation.” The hegemony of biomedicine (and here the author plays with “harmony”—the catchword of TRIPS that instituted the harmonisation of patent agreements between the developed and developing worlds), therefore, involves not only the finished product and its marketing in the global South, but is itself constituted within and through it, thereby reformulating entirely the notion of public health in contemporary India. The author argues that two apparently discrete categories, the standardisation of clinical trials and universalisation of intellectual property, fused together in the making of this hegemony. The consequence of this hegemony is that surplus value, understood by the author in financial as well as normative terms, is generated here through the bodies of the public in developing countries (pp 19–21).

Experimental ‘Labour’

The book is divided into five chapters, besides an introduction and a conclusion. In Chapter 1, “Value, Politics and Knowledge in the Pharmocracy,” the author outlines the political economy of the generation of therapeutic commodities. He argues that the structure of this political economy is embedded in a crisis mode. To put it simply, this is because: first, patents on new therapies or drugs do not last forever; second, the research and development involved in the generation of new drugs is extremely expensive; third, their generation is both time-consuming and risk-prone because most attempts to generate new therapies fail at some stage, usually after considerable time and expense has been spent on them. Fourth, the logic of the stock market (and therefore, the value of the share of the companies) is driven by potential for short-term growth. Therefore, he points out, over the last 25 years or so in particular, pharmaceutical companies have sought expansion through mergers and acquisitions rather than through the more conventional route of research and development.

Once the WTO’s harmonisation policy was agreed to by India, it left the Indian bulk drugs manufacturers vulnerable and unable to pursue their previous, and enormously successful (especially since 1970), policy of “reverse engineering,” that is manufacturing generic drugs, whose patents had expired, in bulk. These bulk drugs were marketed at relatively cheap prices not only in India, but also in other developing countries. Instead, they were now open to being swallowed up, either partially or wholly, by European, American or Japanese pharmaceutical giants. The tendency towards monopoly and the consequent rise in drug prices to match those in the United States (US) affects not just the poor in developing countries. It also stills the monopsonistic national health services in Europe from accessing cheaper drugs from developing countries.

Chapter 2 is titled “Bioethical Values: HPV Vaccines, Public Scandal and Experimental Subjectivity.” Here, the author moves the focus to the rise of the contract research organisation (CRO) industry in India and its role in pharmaceutical innovation, drug discovery and clinical trials with the global pharmaceutical industry. On account of its large illiterate and mostly disenfranchised population who are supposedly more quiescent than any targeted population in developed countries, and also because of the pre-existence of the skills and infrastructure already available, India has been a destination for clinical trials conducted offshore by CROs hired by global pharmaceutical companies since the 1990s. This, incidentally, places the pharmaceutical companies one step away from the messiness of the trials themselves. Rajan’s concern, however, is not the instrumentalist (he terms them “cynical”) connections between the CRO industry, global pharmaceutical companies, and implementation gaps of the ethics regime in place in a country with a skewed development paradigm as in India. Instead, he nurtures his argument around the private initiative-led public health approaches in India that occasioned the unfortunate deaths of girls in Andhra Pradesh and Gujarat in the “post-trial observations” of Gardasil, a vaccine against the human papillomavirus (HPV) that is responsible for cervical cancer, in 2009. This study was approved through the Indian Council of Medical Research, supported by local governments and conducted by PATH, an international non-governmental public health organisation.

The ensuing political furore generated reports and calls for even more stringent ethical norms for clinical trials in a system that is already heavy with regulations. However, the reports could not establish causality of death through the vaccines. Here the author points out that a mere focus on “ethics” does not, and cannot possibly encompass the structural gaps that led to the loss of lives in this case. The “registers of knowledge” (p 103) of the marginalised population in the young bodies of the tribal girls, the universalisation and portability of knowledge that presumed that if they were considered safe in the US they should have been safe in India, and finally the efficacy of a vaccine as the rationalisation for a large-scale public health intervention, which translates knowledge into (material) value had all collapsed in this instance. The fact is that no direct causality could be ascertained to the deaths of the young girls, and the author argues that public advocacy could (and did) turn these girls into political subjects. However, as experimental subjects or political ones, the girls who received the HPV vaccines also comprised the labour of the global pharmaceutical regime, differentiated at various sites within the unequal global network of “knowledge geographies” and within new and innovative modes of production of biomedicine itself. Finally, the author proposes the critical question of the technocratic solution to a public health problem; it is an old one, but bears re-emphasising in the context of the new configurations of power, knowledge and politics of biomedicine itself.

Chapter 3, “Constitutional Values: The Trials of Gleevec and Judicialized Politics,” configures the relationship between constitutional flexibility and intellectual property rights after globalisation. The author examines this through the example of the anti-cancer drug “Gleevec” manufactured by Novartis, one of the largest pharmaceutical companies globally. In 2013, the Supreme Court denied Novartis a patent on the grounds of the flexibility offered in the TRIPS agreement on patents involving public health. Novartis had previously fought this battle in the High Court of Madras before turning to the apex court. The
author deconstructs both the high court’s and the Supreme Court’s verdicts skilfully; particularly in the case of the latter, the judgment rests, he points out, on the interpretation of one constituent of Gleevec that was not new or innovative. Novartis’s claim was that the patent covered all potential modifications to the drug, but did not disclose any particular one, “allowing for a broader monopoly from a patent” (p 133). The Supreme Court ruled that the initial claim was tied to its subsequent manifestations. The author weaves critical questions around this narrative about the politics of constitutionalism and the place of politics within the Constitution, civil society, and the judicial system in India, that made the judgments against the patent for Novartis possible.

Chapter 4, “Philanthropic Values: Corporate Social Responsibility and Monopoly in the Pharmocracy” analyses Glivec International Patient Assistance Program (GIPAP), Novartis’s drug donation programme for Gleevec. The author uses Novartis’s submissions to the patent office in India and the courts to argue that its philanthropic trajectories (Gleevec has been distributed free to patients in 80 countries) support its monopolistic tendencies; and that in turn, this monopoly sustains and enhances the philanthropic engagement. This he demonstrates by asserting that the Cancer Patients Aid Associations, a patients’ advocacy group, claim that the GIPAP programme does not reach as many people as, alternatively, the marketing of the drug at a low cost would have done (according to Novartis, the free distribution of Gleevec has benefited 60,000 people worldwide). Apart from the question of reinforcing monopoly, Rajan demonstrates that Novartis also used the GIPAP programme to attempt to access patient databases in India (p 187). The matrix of medical philanthropy, the generation of knowledge and public health are complex; they cannot be contained within the narrow remits of medical ethics and instead have to be positioned within the structures of the political economy.

A ‘Nationalist’ Drug Industry?

The fifth and final chapter, “Postcolonial Values: Nationalist Industries in Pharmaceutical Empire,” examines the history of the generic therapeutics industry in India through Cipla, a pre-independence pharmaceutical company that has vocally opposed the product patent regimes of the WTO. Rajan traces the history of Cipla through three key transformative moments—the enactment of the drug pricing law in India in the 1970s, the public discourse against the WTO patent protection regime in the 1990s, and finally in Cipla’s advocacy for generic antiretrovirals in 2000–01. He argues that Cipla presents an alternative—a low-cost, nationalistic, and even global humanitarian alternative to the monopolistic and hegemonic global pharmaceutical regimes dominated by pharmaceutical giants from Europe or the US. This alternative, he contends, can be pursued within the bounds of a capitalistic system (and the implication is that it is therefore sustainable), and yet serve public health in wider terms in India and in all developing countries through the manufacturing of low-cost, generic medicines.

And indeed, in the 2000s, Cipla, through developing one method of drug delivery (not an innovation in terms of research and development, but revolutionary in its impact on HIV patients) found itself on the side of civil advocacy groups worldwide against the monopoly of global pharmaceutical giants. In the process, Rajan posits Cipla as the benign, even the only possible, alternative to the oppressive monopoly of global pharmaceutical companies. It is here that I will disagree with the author; Indian generic drug companies have been lax over quality control in the manufacture of generics (Ravinetto et al 2013). Ranbaxy’s exports to Africa, withdrawn by the United Nations, is a case in point (Economic Times 2017). Moreover, given his arguments on the structures of the political economy, it is somewhat disconcerting to find the author offering what is after all a contingent alternative of a “nationalist” company that produces generic drugs for profit as the main protagonist in the resistance to the global hegemony of biomedical drug companies. To say the least, this premise has not held in fact, and Cipla is presently restructuring its organisation and will probably rethink its generic manufacturing model entirely (Somvanshi et al 2017). Moreover, Cipla’s own generic drugs were found wanting and delisted by the WTO in 2004 (Kulkarni 2004).

The reservations I have expressed above do not detract from the intellectual coherence of the book. The WTO and TRIPS agreements have changed the medical market in India beyond recognition, and several scholars have pointed out its various impacts (for instance, Chaudhuri 2005; Bhattacharya 2013; Raut and Majhi 2014). This book’s aim is more ambitious; the author lays bare the hegemony of global biomedical corporations within the political economy of medical knowledge and its normative structures as well as public health in a developing country like India. This book will interest historians and scholars of public health and medicine as well as anyone who is interested in the politics of knowledge in the post-TRIPs regime.

Nandini Bhattacharya ( teaches history at the University of Dundee, Scotland.


Bhattacharya, S K (2013): “Harmonising Patent Laws with the TRIPS Agreement of WTO: India’s Stride Towards Globalisation of Intellectual Properties,” International Journal of Intellectual Property Management, Vol 1, No 3, pp 253–76.

Chaudhuri, S (2005): The WTO and India’s Pharmaceutical Industry: Patent Protection, TRIPS, and Developing Countries, New Delhi: Oxford University Press.

Economic Times (2017): “Ranbaxy in Another Medicine Recall in South Africa,” 18 June,

Kulkarni, Manu N (2004): “Drug Makers, Providers and Users: Opportunities and Challenges in Pharma Sector,” Economic & Political Weekly, Vol 39, No 50, pp 5291–93.

Raut, Tapan Kumar and Bidyadhar Majhi (eds) (2014): WTO, TRIPS, and Geographical Indications (GI), New Delhi: New Century Publications.

Ravinetto, M Raffaella, Thomas P C Dorlo, Jean-Michel Caudron and N S Prashanth (2013): “The Global Impact of Indian Generics on Access to Health,” Indian Journal of Medical Ethics, Vol 10, No 2, pp 118–20.

Somvanshi, Kiran Kabtta, Arijit Barman and Divya Rajagopal (2017): “A Look at How Pharma Giant Cipla Has Lost Its Mojo Over the Years,” Economic Times, 13 Jun,

Updated On : 7th Mar, 2018


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