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191 chapter eight Pharmaceutical Nexus and Globalizing Antimalarials When we analyze the global production and distribution of pharmaceuticals from an ethnographic standpoint, we find areas of practice that defy standardization. A variety of distinct niches—regulatory, medical, ethical , legal, scientific, and economic—related to the anthropological study of pharmaceuticals take specific forms in local contexts and affect individual and collective experience. Enormous differences in drug pricing, for example, stand out as the most politically charged issue of the world’s prescription drug market. adriana petryna, andrew lakoff, and arthur kleinman 2006:14 Pharmaceutical fixes of diseases often constitute the path of least resistance in contexts of underdevelopment, a strategy whereby health promotion eclipses health protection. Reliance on medications to treat diseases and conditions endemic among the poor can result in a “cycle of diseasetreatment -disease” that brings profit to pharmaceutical manufacturers. mark nichter and nancy vuckovic 1994:1512 antimalarials Nexus As with all pharmaceuticals, antimalarials have social lives. They are produced , marketed, prescribed, distributed through formal and informal channels, meet their death through one or another form of consumption , and have lives after death in the form of efficacy in modifying bodies (Whyte et al. 2002:13–14; see also Appadurai 1988; van der Geest, Hardon, and Whyte 1996). On August 27, 2011, I visited one of the largest “wholesale and retail” (jumla na reja reja) pharmaceuticals shops in a crowded street in Dar es Salaam’s Kariakoo market as a starting point to research the social lives of antimalarials amid a rapidly changing antimalarials market. Four Swahili (Muslim) women, with their heads covered in 192 · Philanthrocapitalism a hijab, managed this shop. They were attending to a constant stream of customers, many of whom were buying their prescriptions on a retail basis. I had to wait for about an hour before Zainabu, one of the shop managers, took a break to enter into a conversation with me. The dialogue was about the recent initiative to roll out a 95 percent subsidy for artemisinin-based combination therapies (ACTs) in retail pharmacies. During the conversation , I asked Zainabu if I could take close-up photos of the different, freshly arrived ACTs that were in a pile of boxes behind the counter. She pulled out a sample of each of the six ACTs—three of them were made in India by CIPLA, and three of them by the French pharmaceutical company Sanofi Aventis. “The counter is very busy, you can take these . . . no need to pay, free for you . . . my gift (zawadi) to you,” she said with a generous smile. Her co-worker, who was dressed in a long black Swahili style bui bui and a hijab head covering, was intently following my dialogue with Zainabu. She joined the conversation and asked, Malaria itaisha? (Will malaria finish?). After a brief pause, I posed the question to her, “What do you think?” She responded, “You tell me, you are the expert! (wewe ni mtalaam !)” “I don’t know,” I said. My research assistants, Mariam Mohamed and Robert Kihama, who had accompanied me to the shop, were sitting in two different corners inside the shop. They both gave a half-hearted smile and said, “Haiwezekani” (it’s not possible). Both had recently treated their children for malaria with ACT.1 While Robert had obtained an ACT prescribed at a municipal dispensary free of cost, Mariam had spent Tsh. 6,000 on an ACT she purchased from a retail pharmacy. The wholesale price of the six boxes of the highly subsidized ACTs that Zainabu had offered me as “a gift” was worth a total of Tsh. 1,500 (about $US1). These ACTs were heavily subsidized through the multi-million-dollar Affordable Medicines Facility for Malaria (AMFm) initiative,2 and hence they were astonishingly low-priced at the wholesale shop.3 The co-payments for the AMFm at the time were US$216 million in the pilot phase alone.4 This chapter examines how the complex pharmaceutical nexus involving the global pharmaceutical industry and international donors, that is driving the global antimalarials market, intersects with local pharmaceutical contexts, local practices, and concerns of those who are involved in the pharmaceuticals trade in Tanzania. In other words, I look at the global-local configurations to focus attention on three key questions: How do people involved in the procurement and marketing of antimalarials in Tanzania understand and interpret the recent efforts to make ACT the firstline drug in malaria treatment? How do pharmaceutical wholesalers and retailers explain the continuing...

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