Generic: The Unbranding of Modern Medicine by Jeremy A. Greene (review)

In this thoroughly engaging social, cultural, and political history of generic drugs, Jeremy Greene details the transformation of the generic drug from an object of suspect manufacturing practices and limited regulation in the 1950s to the putative “solution to problems of cost and access in [global] health care” by the early twenty-first century (p. 243). At the center of this transformation were the scientific, clinical, political, and economic debates over generic substitution. In providing this rich account, Greene builds upon the work of scholars who have examined the history and anthropology of generic drugs.¹

Particularly compelling is Greene’s analysis in chapter 9 of the development of New York’s statewide formulary that came to supplant the efforts of the Food and Drug Administration to develop its own list of interchangeable generic drugs in the late 1970s. In the 1980s, Greene argues, while the American Medical Association and the research-based pharmaceutical industry came to accept the legality of generic substitution, the political debate shifted to the interchangeability of “me-too” drugs. Chapter 12 is instructive because using the examples of “me-too” cephalosporins, which were interchangeable, and beta-blockers, which were not, Greene makes explicit that the debates over substitution were about much more than politics and economics; they had very real clinical stakes.

To great effect, Generic is organized thematically. Greene takes the reader through the failed efforts by the World Health Organization, the United States Pharmacopeia, and the AMA to develop a standardized system of drug naming in the 1950s; the emergence of a “self-effacing” (p. 64) generic drug industry amid the political critique of the research-based pharmaceutical manufacturers in the 1960s and 1970s; the development of the sciences of similarity that underpinned the FDA’s more stringent regulation of generic drugs by the mid-1970s; the competing interests of consumer politics and the generic drug industry’s marketing practices in the 1970s and 1980s; and the more recent debates about the politics and economics of generic drugs.

Rather than leading to chronological redundancies, as can often happen in thematically structured books, this structure allows Greene to highlight the persistent paradox of generic drugs: throughout their history, advocates of generic drugs have seen in them the promise of cheaper, therapeutically equivalent prescription drugs. In turn, generic drug manufacturers based in the United States and Europe, and to an even greater extent those based in the Global South (particularly in India and Brazil), have been held up as the Davids to the multinational research-based pharmaceutical Goliaths. Yet, as Greene compellingly shows, rarely have these visions borne out. Therapeutic equivalence, as clinical, regulatory, and political reality, remained contested (and continues to do so as the FDA evaluates how to establish a regulatory pathway for biosimilars), and the availability of cheaper generics did not guarantee that pharmaceutical consumers would actually choose those drugs over more expensive brand-name drugs. As shown in the book’s fascinating section on generic consumption (chaps. 10 and 11), in the 1970s, generic manufacturers ventured into the field of consumer research and generic marketing in an attempt to sway these reluctant generic consumers. In doing so they began adopting the traits of the research-based drug firms, so much so that by the early twenty-first century, the biggest generic drug manufacturers are now multinational giants. By underscoring this paradox, Greene builds on the scholarship of Kaushik Sunder Rajan and Stefan Ecks on the Indian generic drug industry, João Biehl on the Brazilian generic drug industry, and Cori Hayden on generic drugs in Mexico, all work that challenges overdetermined analyses of the pharmaceutical market in the global neoliberal political economy.²

In sum, Greene’s Generic: The Unbranding of Modern Medicine is an excellent study in the recent history of prescription drugs and the intersection of consumerism and marketing in the post–World War II U.S. health care system, offering valuable perspectives on the recent...