Pharmaceutical Governance: Commercial Science, State, and Patient Populations in Brazil João Biehl Abstract: As biotechnology-related patents flood the United States Patent Office promising potential though as yet unrealized gene-based treatments and hope, new pharmaceuticals in the form of psychotropics, anti-cancer agents, and anti-retrovirals are already part of a booming global market in health that is mediated by patient's claims and alternative forms of social mobilization and of health delivery, all linked to the demands of profit of finance capital and to the medical agendas established through First World politics. My ethnographic work addresses the ways in which science and technology are integrated into governance, the mediations by which new medical markets and patient populations are constituted, and the kind of persons and moral action being fostered amid the growing tension between health as public or private good and the constitution of triage-like states. This paper focuses on the biotechnological control of AIDS in Brazil. In 1992, the World Bank and the Brazilian government approved an unprecedented 250 million dollars aid package for the creation of a new national AIDS Program whose aim was to reverse what international experts were calling the "africanization" of AIDS in Brazil. Activists, politicians, economists, and scientists organized an impressive governmental and non-governmental administrative apparatus that is believed to have contained the epidemic's growth through massive and community-mediated prevention projects, with a particular focus on so called high risk groups. In 1996, national data began to show a decrease in the epidemic's rate of growth. According to Dr. Paulo Teixeira, Brazil's current AIDS coordinator, "we were able to avert half of the projected 1,2 million HIV cases." After the US, Brazil has the second highest HIV prevalence in the Americas, with official governmental estimates of some 600,000 infected out of a population of more than 170 million people. In November 1996, the Brazilian government made history by passing a law that made combined antiretroviral therapies freely available to all registered AIDS patients. As of 2002, there were some 115,000 patients taking antiretrovirals. The availability of the cocktail and lab-testing, funded by the Brazilian government at an annual cost of some 2,500 dollars per patient (in the US the cost is around 15,000 dollars), is said to have reduced the demand for hospital services and AIDS mortality by more than 50 % in São Paulo and Rio de Janeiro, the most affected areas of the country, and HIV transmission from mother to child is said to have been reduced by two thirds. This policy of biotechnology for the people is being hailed as a "proof that poor nations can do it" and "a model for treating AIDS worldwide," as Tina Rosenberg from the New York Times has put it, and the Brazil story is now an important component to international medical activism. In the face of the devastation brought up by AIDS, the unlikely availability of a vaccine in the near future, and the relatively few interventions that seem replicable this is a most welcome success story. But before acquiring ethical currency and export value, I am concerned with what happens locally: how this specific AIDS control has politically come into existence and how the modeling of life and death of certain populations has become a cost-effective thing and with which effects. I am currently working on a book entitled Pharmaceutical Governance that documents how this model of accountability has come into existence, and that critically assesses its social reach and medical and political impact. From 1995 to 1997, and in the last three summers I carried out fieldwork in state, corporate, scientific, non-governmental and local public health institutions, whose restructuring went hand-in-hand with what I call the Brazilian AIDS transition. I also worked in community-run services and with marginal populations living with AIDS in the streets and without access to care in southern and northeastern Brazil, combining both qualitative and quantitative methods of investigation. The realities I documented have been engineered as novel assemblages of international financial institutions, commercial science, a reforming state and non-governmental mobilization in a context of entrenched inequality. These assemblages have to be placed in critical and political perspective as they are entangled with and give new form to the question that remains at the core of sovereignty and social experience: who shall die and who shall live? As I think though the Brazilian control of AIDS, I am particularly concerned with the rational, technical and political dynamics and ordinary practices through which the decision over letting die and making live is realized. The ethnographic task is to bring to public light and to think through what happens in the meantime, what remains unfinished as Brazil's new political paradigm comes to life. |