Pharmocracy: Value, Politics, and Knowledge in Global Biomedicine by Kaushik Sunder Rajan (review)

Global scandals involving human biology, such as transnational drug testing, organ trade, and surrogacy often make the clinic ground zero of transgression. Formal or informal, legitimate or underground, clinics help us tell a particular kind of story, in which scientific practice allows global capital's extractive demands to prey on structural inequality and override principles of justice.

But what if we imagine the global traffic in health commodities, including drugs and the biologies they interact with, from a different site? Not the clinic, but the trial. Might a different story emerge? This question is posed by Kaushik Sunder Rajan in Pharmocracy: Value, Politics, and Knowledge in Global Biomedicine, a masterful ethnography of global pharmaceutical practice as social and civic process.

Pharmocracy focuses on the hub of the cosmopolitan drug trade that is India in the post-TRIPS (Trade-Related International Property Rights agreement) era, following WTO-mandated changes to India's drug patent laws, a decision intended to bring the Indian pharmaceutical industry—provider of cheap drugs to the world—in line with European patent rules. Coinciding with an increase in clinical trials in India, principles of "harmonization" guided global regulations, with the aims of standardizing transnational drug testing and remaking patent laws to match Euro-American ones.

"Trial" here is meant doubly—drug trials and legal trials. Rajan focuses on two scandals involving trials, both instances of civic grappling with the impact of new pharmaceutical paradigms. Rajan's innovation is to hold several senses of trial in the same frame as conjoined sites of knowledge, materiality, and human need. In one, several young women died during an NGO-supported HPV vaccine trial aligned with women's health activism. In the other, the Indian high court evaluated patients' right to access a cancer drug, deliberating the value of corporations and care. The trials rearrange the usual array of actors into new alliances. Together they expose the ways pharmaceutical politics—and the bioethical conversations they generate—are forms of social action, highlighting the new era's most vivid contradiction: access to medicine for the poor is constricted at the same time that bodies of the poor become available for pharmaceutical trials.

In doubling the meaning of "trial," Rajan juxtaposes institutions and infrastructures. Biomedicine and legal systems work together, but in different "trials" serve different ends. Within the overarching imaginary of "health," contradictory goals might be concealed, but by contrasting different convergences of the same infrastructural and social domains, Rajan explores contrapuntal effects. These include the way, in the drug trial in question, biomedical knowledge is politicized, while in the court case, access to pharmaceuticals is "judicialized" (c.f. Biehl 2013). The basic irony—less drugs, more drug testing—translates into different mobilizations of civic process; as Rajan writes, it is important that "in the same place (India), at the same time (2000s), in the same industrial sector (concerning pharmaceuticals and health), one can have such different trajectories of political contestation, which intersect and interact with globally hegemonic movements in political economy" (12).

Other anthropologists have recognized courts as sites of bioethical reckoning through rights discourse, considering the collaboration of courts and clinics instrumental sites of biopolitical management (Biehl 2013, Biehl and Petryna 2011). The context of India offers certain histories, including the impact of the Bhopal disaster on health activism and a long history of state invocation of parens patriae over citizens' claims.

In this context, there are many ways in which the multiplicity of "trial" is fruitful. As well as highlighting contradiction, focus on trials emphasizes the openness of political processes. While clinics and trials are equally teleological and subjunctive, trials involve a particular kind of opening up. They deploy and evaluate knowledge simultaneously, working at once with and toward notions of value. In the cases Rajan explores, trials are an invitation to questions of value: how is a thing, a person, an effect, an act, an ethic, to be valued? How is it to be valued against another?

Also compelling is the...