Questioning the Bifurcations in Global Health Discourses

In October 2008 I was in my first semester on the faculty at Georgia Tech and keen to meet other scholars and activists in Atlanta with whom I might share interests. One afternoon, I took the bus to nearby Emory University to attend the "International Access to Medicines" panel of a human rights conference held at the School of Law. It was a decision that I made on a whim, but it would turn out to be a fateful one. That panel was where I first learned about the small South African pharmaceutical company that would become my field site: iThemba Pharmaceuticals.

The panel focused on access to medicines in poor countries. One of the speakers was an Emory chemistry professor, Dennis Liotta, a prominent drug discovery scientist. Liotta and his collaborators were the researchers who discovered the key components of second-generation antiretrovirals, the HIV/AIDS drugs used in rich countries today. To an auditorium filled with people overwhelmingly of the opinion that increasing access to drugs would require reform of intellectual property (IP) laws, Liotta described an intriguing alternative approach. With passion in his voice as he methodically laid out his argument, Liotta made a case that the problem was not IP per se, but who owned it. He argued that the fact that IP is overwhelmingly owned by those in rich countries makes access to its products unaffordable to those in poor ones. Liotta argued that if drugs were discovered in developing countries and if companies based in those countries owned the IP, the drugs would be affordable to the poor and would be relevant to their needs. Building on this premise, he described two ways that he was trying to make it possible for African scientists to discover innovative drugs.

He first outlined a conventional model of knowledge transfer in which he was involved: a postdoctoral program that brought South African scientists to Emory to be trained in drug discovery. Yet Liotta pointed out that if the training happened without regard to the South African economy, it would only exacerbate brain drain. The scientists' skills would be unemployable in their own country if there were no companies in South Africa that could hire drug discovery scientists. He then described an intriguing complementary approach, exemplified by another initiative in which he was involved: a company that he was in the process of launching, called iThemba Pharmaceuticals, which was going to do research on diseases of the poor in South Africa. The start-up would be set up as a for-profit company, but with lower labor costs than such a company would have in a place like the United States, and with a public mission that would tolerate the lower profit margins of treatments for diseases that disproportionately affect the world's poor. The company would be a way to build scientific knowledge capacity in Africa, mitigating brain drain while also, it was hoped, finding new drugs that would be affordable to the global poor and relevant to their needs. I was immediately intrigued by an element of this project that struck me as unique: it linked the availability of drugs with the capacity for scientific knowledge making while paying attention to place. And, as I will describe, place was simultaneously geographical, political, logistical, and imaginative.

iThemba was a small company on the outskirts of Johannesburg that opened its doors in 2009, a fresh start after an earlier Cape Town–based effort had foundered. It was cofounded by Liotta and other elite scientists to find new drugs for TB, HIV, and malaria. It received start-up funding from the South African government, which owned half of the company. iThemba's founding mission, "inexpensive therapy for infectious disease through innovative chemistry," was a distinctive one. To illuminate this distinctiveness, in this chapter I will contrast iThemba's approach with that of the three most prominent discourses of pharmaceuticals and the Global South: access to medicines; bioprospecting; and clinical trials. Putting iThemba into comparative relief with these disparate sets of discourses reveals a common element among them. All three have an implicit reliance on a problematic conceptual bifurcation between Global North and South. South Africa itself is in many ways betwixt and between Global North and South, and this small drug discovery company's mission helps to illuminate some of the limitations of pharmaceutical knowledge-making projects that take that global bifurcation for granted.

Placing Pharmaceutical Knowledge Making: Beyond Access-to-Medicines Campaigns

In Liotta's comments at the conference on human rights and the law, I was struck that iThemba's approach differed from most approaches to solving the urgent health needs of Africans, which all frame the lack of access to drugs in poor countries as a failure to meet the needs of the Other. These initiatives are widely known as access-to-medicines campaigns, using the terminology of the campaign spearheaded by the nongovernmental organization Doctors without Borders, which aims to both increase access to existing drugs in poor countries and address the lack of investment in research and development directed toward treatments for the world's poor. Here, I will describe ways in which wide-ranging access-to-medicines campaigns — whether they promote distribution of generic drugs or incentivize researchers in the Global North to focus on diseases of the poor or attempt to do both — perpetuate global divisions in access to knowledge and power. Global health discourse recapitulates a troubling colonial legacy when "it configure[s] through language 'others' who would be the objects of research and the recipients of redistribution." Access-to-medicines campaigns can reinforce a bifurcation of the world between (1) knowledge creators who have a moral duty to create and share knowledge and (2) those in desperate need.

This geographic bifurcation between places of knowledge production and places where the only question is access is pervasive. For example, Universities Allied for Essential Medicines emphasizes the moral emergency of the lack of access to existing drugs and lack of research into diseases of the world's poor. Their solutions center on North American and European research universities sharing the fruits of their pharmaceutical knowledge with the Global South. Their motto — "our drugs, our labs, our responsibility" — is at once compelling and peculiar. The "our" locates but also circumscribes, implying that the only place that knowledge can be produced, and the only place that responsibility can be located, is in the Global North. The slogan reinforces the Global North's ownership claim to scientific knowledge at the same time that it advocates widening the scope of that knowledge's...