Abstract
What is the value of a medication? In Living Worth: Value and Values in Global Pharmaceutical Markets, social anthropologist Stefan Ecks uses the case of antidepressants to consider how life and medicine are valued amid the global movement of pharmaceuticals. Chapter by chapter, Ecks grapples with the tensions embedded in contemporary issues relating to the value of medicine through case studies. These include interrogations of philosophical, anthropological, and economic differences in conceptions of value, how international and consensus-based health initiatives consider context and culture in their deployment, and how the global pharmaceutical industry imperfectly exports marketing materials to local contexts. The result is eleven case studies that take these contradictions as a starting point for further theoretical or empirical analyses. With such a diverse range of topics tackled, what ties these chapters together is a focus on values and cognate concepts like commensurations, consensuses, similarities, and differences. Combining these elements, Ecks presents a theory of biocommensuration, or a process of valuing that involves transactions that aim to improve life. He draws on case studies from around the globe, taking the reader to India, the United States, and the United Kingdom to consider how objects, spaces, and habits shape biocommensurations in psychiatry.
Interrogating such a broad topic—how value is constructed in the global pharmaceutical industry—in a single book would be nearly impossible were it not for Ecks’s mastery of a wide breadth of theory. A strength of the book is how Ecks brings together theories of value from different disciplines and puts them in conversation with each other, including works from anthropology, philosophy, economics, sociology, and science and technology studies. The result is a few primarily theoretical chapters in the beginning of the book that set up more empirical arguments carried forward later, including an embodied theory of value (“Embodied Value Theory”), an evaluation of theories of relative value and the issue of comparisons in the social sciences (“Relative Value: Culture, Comparison, Commensurability”), and an interrogation of how other kinds of value can be incorporated into Marx’s labor theory of value (“Never Enough: Markets in Life”). These arguments highlight Ecks’s ability to synthesize ideas and concepts from disciplines with divergent assumptions about human behavior and social life.
Even with this theoretical mastery, analyzing value and values across the global pharmaceutical industry, disparate national health care systems and patent laws, and local cultures of medicine is no small task. To gain a foothold in this complex web of patent laws, health care systems, and cultural contexts, Ecks focuses on how things or objects are implicated in value judgments. These things addressed include the sixth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), Indian pharmaceutical advertisements in English, and official statistics about global depression rates. Notably, these things are products of elite expertise and are sites for Ecks to explore important implicit and explicit valuations for the global and capitalist pharmaceutical market. For example, Chapter Eight (“Culture, Context, and Consensus: Comparing Symptoms and Things) highlights how the changes in the sixth edition of the DSM are important to U.S. psychiatrists because specific diagnostic codes are required for all insurance reimbursements, thus creating a context where the DSM is important for monetary value. He notes that the DSM is relatively inconsequential in India, where patients mainly pay for medications out of pocket. The DSM is commonly used in the United States, but the International Classification of Diseases (ICD) is much more common outside the United States. I would be interested in reading Ecks’s assessment of how the ICD or other relevant guides produce value in India.
Another major theme of Living Worth is the tension between the logics of the global pharmaceutical industry and local psychiatric practices. Chapter Four offers a particularly compelling analysis of the tensions between global pharmaceutical forces and local contexts. Ecks takes the reader to a Pfizer symposium on antidepressants in Kolkata and describes a puzzling act of intended corporate social responsibility. Pfizer developed a questionnaire in English for diagnosing depression accessible to non-experts, translated it into six South Asian languages, and piloted it on thousands of patients. However, the Pfizer representatives at the symposium did not recommend sharing the diagnostic tool with patients. Ecks asks: why would Pfizer go through the trouble of making a public-facing diagnostic tool and then recommend not sharing it with the public? He turns to a concept he terms “near-liberalism” to make sense of the contradictions in neoliberalism as they get deployed in local contexts. Such contradictions include corporate practices that tend toward empowering patients and emancipation, like the democratization and availability of public-facing depression diagnostic checklists, but also include contradictory elements that suspend patient empowerment practices as soon as they interfere with profits.
Some of the highlights of Living Worth include how Ecks incorporates ethnographic evidence into his theoretical arguments. These moments effectively serve to highlight the real-world stakes of sometimes abstract arguments. For example, he takes the reader to a pharmacy in Kolkata in Chapter Nine (“Generic: Distinguishing Good Similarity from Bad Similarity”) to examine how similarly valued objects are differentiated through a case study of generic medications in India. India is one of the world’s major exporters of generic medications, which means there are many versions of the same drug to choose from when a physician writes a prescription. The large number of choices available presents a problem for pharmacists in Kolkata, who in turn must stock many offerings of the same kind of medication.
In other chapters, Ecks’s argument would be enhanced by including more empirical context. For example, in Chapter Seven (“Acting through Other [Prescribing] Habits”) he questions the claim that patients are causing global rates of depression and anxiety to rise by turning the focus to physicians’ prescribing habits. He introduces an argument for “habitology,” or the study of how individuals engage in nonreflexive, embodied, and routine valuing practices, as an alternative to ethnography. He provides this interesting framework for the theoretical history of related concepts, like Mol’s praxiography, Latour’s theories of nonhuman agency, Weber’s habit, and Mauss’s and Bourdieu’s conceptions of habitus. This is an interesting discussion that evaluates norms, practices, and habits, but it is missing an empirical assessment of his own claims about habitology. Overall, the lack of empirical description, ethnographic illustrations, and reflections about the field research process detract from the arguments in the book.
Living Worth is an excellent resource for students and scholars investigating interdisciplinary theories of value. Ecks’s theoretical framework and case studies provide substance that both advanced undergraduate students and scholars in sociology and anthropology will find interesting and useful.