Generous corporations? A Maussian analysis of international drug donations

Introduction

On 10 October 2016, the US branch of Doctors Without Borders published a letter online entitled “There is no such thing as ‘free’ vaccines: Why we rejected Pfizer’s donation offer of pneumonia vaccines.” The letter explains why drug donations are inadequate, as they often “involve numerous conditions and strings attached” and can be used “as justification for why prices remain high for other” drugs (MSF Access Campaign, 2016). Yet, drug donations are a traditional tool used in the fight against global diseases. In front of the World Health Organization (WHO) headquarters in Geneva, a sculpture represents an African child leading a blind man, symbolizing the success of the fight against onchocerciasis, also known as river blindness, made possible through Merck & Co’s donation of ivermectin, brandname Mectizan, since 1987. In-kind drug donations are unrelentingly popular among pharmaceutical companies. They represent about 90% of the $7.6 billion in US corporate giving (Currie-Alder et al., 2014: 807) and enable US pharma companies to “routinely dominate the list of the most generous companies in America” (LaMattina, 2013).

But can corporate actors be “generous”? Is it not paradoxical to call this philanthropic practice donation, which suggests that it belongs to the sphere of gift-giving, when, as the statement by Doctors Without Borders makes clear, instrumental interests are at play?

Drug donations refer to the practice of giving medicines for free, outside of the drug market, with the ultimate goal of reaching populations in need. There are three different forms of drug donations by pharmaceutical companies (Bates, 1999: 89): inventory donations of soon-to-be expired or over-produced drugs (the most frequent case); donations of commercial drugs at the request of an organization to respond to a humanitarian disaster or contribute to health development programs; and donations of specifically produced drugs, not otherwise available on the market (a rare case). They can be of two kinds: emergency relief donations and long-term aid donations. The former are short-term, following an emergency situation due to a natural disaster (earthquake, tsunami, etc.) or crisis (war, epidemic outbreak, etc.). The latter are long-term donations more akin to development aid and tend to take the form of institutional programs. For instance, Merck has donated Mectizan (ivermectin) since 1987 through the Mectizan donation program to fight onchocerciasis (also known as river blindness) in West Africa.

When a donation occurs, an object (a drug) otherwise sold on the market (even if sometimes at a subsidized price), and usually subject to a specific commercial process, enters a different circuit and distribution system. Yet, even if drug donations seem to break with the logic of exchange constitutive of the market, they are intimately linked to market dynamics. This is especially true in the case of corporate drug donations, because of the for-profit nature of the donor and the presence of ulterior motives.

In The Gift, Marcel Mauss provides an analysis of the reproduction of society through a triple obligation to give, receive, and reciprocate. Thus, the gift is characterized by a combination of freedom and obligation and shaped by reciprocal expectations, although there is no guarantee, since reciprocity here is not contractual. Contradicting Bronislaw Malinowski’s insight from his fieldwork in Melanesia that the domains of commerce and of the gift are separate, Mauss shows that there is no pure gift and no free gift, and that gift-giving is a form of social interaction that is neither on the side of self-interest nor of morality (Adloff and Mau, 2006: 95). A free gift does not exist: it would be asocial. The triple obligation initiates a perpetual cycle of exchange intertwined with the whole society. Gift-giving is an interaction involving cycles which “engage persons in permanent commitments that articulate the dominant institutions” (Douglas, 1990: ix–xii).

However, even if there is no free gift, gift theorists, building on Mauss’ essay, have described the exchange of gifts as fundamentally different from market exchanges (Godbout, 2000). The sphere of gift-giving requires tacit cooperation mechanisms (such as non-contractual reciprocity); rules have to be implicit (Godbout, 2000: 11). Gifts exchanged create social links and ensure their perpetuation, and thus gift-giving’s temporality is infinite. On the contrary, the market sphere is characterized by its explicitness and the search for equivalence—this is epitomized in the signature of contracts and the existence of a price system. Furthermore, the temporal horizon of market exchanges is finite. In this understanding, drug donations would probably not belong to the domain of the gift, they would be “false gifts,” belonging to the domain of the market. It might even be argued, along with critical theorists such as Adorno (2005), that the “decay of giving” is irreversible in a global market society dominated by economic rationality and the “exchange principle” (2005: 42). Any attempt to make sense of drug donation practices would then clearly link them to the domain of the market, an interpretation also shared by a utilitarian approach.

As Mary Douglas (1990) puts it, “If we persist in thinking that gifts ought to be free and pure, we will always fail to recognize our own grand cycles of exchanges” (1990: xx). I would add that if we persist in focusing on the fact that gift-giving and market exchanges are fundamentally different and thus distinct most of the time, we might not be able to understand some characteristics of our global society, such as the persistence of corporate drug donations. They continue to exist and blossom, even though they are criticized for belonging to an age of “charity aid” which has proved inefficient, and even though they are at odds with the evolution of philanthropy—sometimes subsumed under the term “philanthrocapitalism”—where the legitimacy of economic or instrumental interests has explicitly joined, if not replaced, that of altruistic and moral motives. I think that Marcel Mauss’ The Gift can prove fruitful in analyzing this complex intertwining of the domains of the gift and of commerce at the global level.

This is why in this article I argue that the practice of corporate drug donations can be explained with the help of a Maussian understanding of the gift. Accordingly, gift-giving is not disinterested and does not have to result from pure altruism, but can very well be part of a larger process of accumulating wealth and power, just as Mauss described with the potlatch and kula exchanges. The potlatch is a system of “total services of an agonistic type” characterized by “very acute rivalry and the destruction of wealth”: every gift has to be reciprocated, often with the aim to outdo the previous one, to establish a hierarchy (Mauss, 1925 [1990]: 8). The kula is a system of ceremonial exchanges based on circular reciprocity: the objects exchanged are used to forge social relationships and enhance trust among tribes (Mauss, 1925 [1990]: 27–39). Gift-giving has nothing to do with “doing good” or “being nice.” The fact that corporations have ulterior motives, are using drug donations for public relations purposes, to enter new markets, avoid regulations, or maintain peace within their workforce—in other words, that corporate drug donations are about power and accumulation—is what makes them a gift in the very Maussian sense of the term.

Building on this basis, four elements from Mauss’ theory of the gift seem to be very fruitful in analyzing drug donations from pharmaceutical companies. First, Mauss argued that gift-giving and the triple obligation to give, receive, and reciprocate transformed conflicts into alliances and built chains of reciprocity. The idea helps analyze the role pharmaceutical corporations have gradually taken in global health governance. Second, the Maussian criticism of the “gift as charity” is extremely relevant in the case of drug donations, which have been denounced in terms that are not unrelated to the criticism of the “injurious patronage of the rich almsgiver” (Mauss, 1925 [1990]: 83). Third, The Gift questions the definition of interests and their role in driving human actions. This is a key element of the essay, one that has been heavily debated, as was intended by Mauss in his opposition to utilitarianism. The complex relation between gift-giving and interest not only sheds light on corporate philanthropic practices but also questions the intertwining of the domains of the gift and of commerce, as, for instance, in the common instrumental use of gift-giving by merchants (Godbout, 2000: 115). Fourth, The Gift raises important questions for theories of social justice, especially in its fourth and concluding part, although they remain conceptually underdeveloped. The understanding of welfare politics as some sort of “counter-gift” for the work of individuals helps frame ethical issues and question the legitimacy of global health policies for access to medicines.

Methodologically, these four Maussian elements can, of course, not all be used in the same way. Some have to undergo major adaptations, and overall, they are tools or incentives to think about social interactions between different types of actors and the reproduction of social order at the global level. We especially have to take into account the fact that the context of contemporary drug donations is quite different from the one Mauss developed his theory upon. In the Essay, gift-giving is described as an interaction taking place between persons in “archaic” societies. Here, exchanges take place between organizations typical of modern society—corporations, private foundations, non-governmental organizations (NGOs), governments, and international organizations. Large transnational pharmaceutical corporations in particular are products of late modernity, and especially of scientific progress, capitalism, and globalization. The pharmaceutical industry emerged at the end of the nineteenth century, and transnational pharmaceutical corporations flourished after World War II. In the late twentieth century, they entered a process of differentiation (between research and development (R&D) and generic firms) and mergers, which left only about 20 large R&D-based pharmaceutical companies—“Big Pharma” companies—that are very profitable. These organizations are made up of individuals who decide whether to donate a drug and to respond to human needs. Donated drugs are also meant to reach individuals in the end. But the donation is mediated through several intermediary organizations (NGOs, private foundations, the State, etc.), something that is also typical of modern society. This is a major difference with archaic societies, which raises the question of whether gift-giving plays the same role and is equally fundamental to both archaic and modern societies, and whether it is still systemic in modern society. ¹

Before we reach this point, the four sections of this article will show that a Maussian framework is useful both empirically, for making sense of corporate drug donations, and theoretically, for contributing to the study of corporations as political actors and to global justice theory. The first section of the article will make sense of why and how drug donations are criticized, especially by NGOs. The second section will analyze how corporate drug donations are used to defuse conflicts and build alliances within the context of global health policies. The third section aims at “opening the black box” of corporations and analyzing the plurality of their interests, which can help better conceptualize them as actors. Finally, the fourth section will draw implications for social justice theory.

Charity-based drug donations and the permanence of health inequalities

Drug donations in general, and corporate ones in particular, are controversial practices (Guilloux and Moon, 2001). Contestation, mainly expressed by NGOs such as MSF, builds on two rationales. The first refers to what we can call adequacy problems: their costs can be extremely high for recipients, sometimes higher than the value of the drugs (e.g. storage costs), the drugs can be inappropriate (or expired), and so on. The second rationale refers to structural problems: drug donations are only a temporary fix which does not address the underlying conditions of access to medicines.

There are two main components of access to medicines: availability and affordability. Drugs have to be produced, and in the right quantities (e.g. there need to be R&D efforts to discover and manufacture the drugs), distribution circuits have to be put in place (which, for instance, necessitates adequate health systems), and drugs have to be affordable (which requires pricing that is in line with patient solvency). A deficiency in any of these sectors compromises access.

Global inequalities are blatant and deficiencies exist in each of these areas. In total, it is estimated that one-third of the world population, so about 2 billion people, lack adequate access to medicines. ² R&D is focused on finding drugs for diseases affecting populations with the means to pay in developed countries. It is estimated that 90% of the global disease burden attracts only 10% of research funds. ³

But even if a treatment has been developed and health infrastructure is in place to distribute it, the price often remains a hurdle. The fixing of prices depends on the structure of the drug market (and especially on how many producers there are and if there is a monopoly or not), which is itself highly dependent on intellectual property rights. Intellectual property rights enable inventors to patent innovations and gain a monopoly over them, which allows inventors to monetize innovations and ensure the existence of a market. The strengthening of the global intellectual property regime since 1994 and the signing of the Agreement on Trade-Related aspects of Intellectual Property Rights (TRIPS), which extends and expands drug patents, and limits exceptions on patentability, made pricing an even more acute problem. The new regime gave rise to numerous conflicts between R&D pharmaceutical corporations, generic pharmaceutical companies, governments, and NGOs.

Both the adequacy problem and the structural problem of drug donations underline the fact that they place recipient countries in a situation of dependency. This echoes Mauss’ denunciation of faulty gift-giving practices that give rise to hierarchical relations and relations of dependency (Ramel, 2015: 194). In the last part of the The Gift, Mauss (1925 [1990]) writes, “Charity is still wounding for him who has accepted it, and the whole tendency of our morality is to strive to do away with the unconscious and injurious patronage of the rich almsgiver” (1925 [1990]: 83; emphasis added). And indeed, drug donations from pharmaceutical companies tend to have a one-sided design with little beneficiary involvement. This has three main consequences: recipient countries are placed in a situation of dependency, governments and populations are deprived of ownership/empowerment over access to medicine policies, and sustainability is not guaranteed, which raises great health concerns. These problems are associated with all types of donations, whether short- or long-term, and whether they involve inventory, commercial, or specially produced drugs. In the case of emergencies, it has been argued that because of the temporary and exceptional character of the donation, solidarity prevails over any demeaning aspect of charity (Godbout, 2000: 260). However, even if solidarity mechanisms are at play in case of natural disasters for instance, the conditions in which they are displayed show that drug donations are still unilateral acts.

For instance, the response to the tsunami that affected Sri Lanka in 2004 stands as an example of inadequate and even damaging drug donations (Bero et al., 2010: 924). Requests by the Sri Lankan Ministry of Health were ignored. Of the 56 tons of drugs received, only 10% were on the list of requested medications (WHO, 2011: 19). Several unfortunately common problems arose, linked to the drugs themselves (inadequate quality, shelf-life, presentation, packaging, and labeling), to the fact that the country’s needs were not taken into account, and that national/local pharmaceutical procedures were not respected. It has to be noted that once received, drug donations cannot be returned to donors “because they are considered hazardous cargo and their shipment must respect the Basel Convention on the Control of Transboundary Movements of Hazardous Wastes and their Disposal” (Pinheiro, 2008: 580). This means that the recipient country has to manage handling costs (taxes, storage, transport) and bear any additional side effects (stockpiling of unused medicines may favor sales on the black market, leading to inappropriate use, etc.).

But one-sided design and lack of acknowledgment of, and consultation with, recipients is not specific to emergency drug donations. A study for the 2010 WHO Bulletin found that “none of the long-term donation programs originated in response to a specific request from a country” (Bero et al., 2010: 924). They are usually put into place at a regional level, to treat endemic diseases on a larger scale, and are managed through international organizations. For instance, recipient countries were not consulted in the setup of the Mectizan Donation Program, which Merck launched in 1987 to fight onchocerciasis (also known as river blindness) in West Africa (Guilbaud, 2015a). Mectizan is the brandname of a molecule, ivermectin, a broad-spectrum antiparasitic used in the treatment of worm-caused diseases in humans and animals. The molecule is hugely lucrative on the veterinary market and is not marketed for human treatment of onchocerciasis. Mectizan is produced only for the donation program, because affected people could in no way afford to pay for it. To design the program, the company turned to the WHO, which had its own program to fight the disease in the region (the Onchocerciasis Control Program), and to an NGO which hosted the Secretariat of the Program (the Task Force for Global Health). However, cooperation remains limited to other global health actors. Recipient countries are not major partners. They submit applications to receive Mectizan through their health ministries. Applications are evaluated by members of the Mectizan Expert Committee, convened and managed by the Task Force for Global Health. Furthermore, Merck keeps complete control over shipping, a key stage of the Mectizan distribution process. Once the Mectizan Expert Committee reaches a decision on donation approval (what organization will receive the drug for distribution and in what quantities), Merck Corporate Contributions sends the drugs from the company export department located in Riom (France) and controls the process until the drug has reached its final destination (Guilbaud, 2015a). The firm manages this stage of the process single-handedly, despite requests from countries or local organizations that Mectizan should be stockpiled directly on the ground in countries so that governmental or local agencies can have more room to maneuver and decide, for instance, when to distribute the drug (which has to be taken once a year; Levine, 2005: 67).

Thus, even in the rare case of a drug produced entirely for donation, decisions on whether to set up a donation program and on how to implement it remain a unilateral process and bypass local governments. The fact that populations affected by onchocerciasis would not be able to afford the drug at the price Merck would fix was used to justify the donation and to frame it as a charity measure, placing beneficiaries in a long-term dependency situation.

To underline the consequences of dependency, we should note that quite often, the sustainability of the program is not guaranteed, and donations are limited in time. Although the Mectizan donation program did not set time limits—it was decided from the start in 1987 that the donation would last as long as needed—this tends to be the exception. Numerous cases have been reported of abruptly stopped donations. The Malarone donation program, for instance, was only effective between 1999 and 2001 (GSK refused to enter in a permanent agreement to donate the drug; Olukayode Oyediran, 2002; Reich, 2002: 13). In 2016, Uganda faced a shortage of Diflucan, despite Pfizer’s commitment to donate the anti-meningitis drug to the government (MSF Access Campaign, 2016). In another case, Novartis prematurely suspended its imatinib (Glivec) donation program in India, because the government authorized production of a generic equivalent (Strom and Fleischer-Black, 2003). Recipient countries then face the dilemma of either finding funds to pay for the molecule or stopping providing it to patients in need.

Corporate control over donation drugs also has negative effects on ownership of health policies, which refers to a government’s capacity to manage, control, and thus to be engaged with, the health need of its population. Lack of room to maneuver can fence in governments in a vicious circle of disengagement. In addition, such donations tend to diminish people’s empowerment in their access to drugs. In the case of Mectizan for instance, most people are unaware who manufactures the drug and have no control on when they will have to take the medicine. In some cases, lack of scheduling control has led to problems when distribution occurred while men were seasonally away from their villages, working (Hopkins, 1998: 99).

Drug donations can also create or reinforce inequalities because they are always very specifically designed: who can benefit from the drugs and for what disease is the object of a clear contract between the giver and the beneficiary. A drug that could be used to treat multiple conditions can be restricted to the scope of a donation program. For instance, Zithromax, given by Pfizer through the International Trachoma Initiative, is a large-spectrum antibiotic, but can only be donated to fight trachoma. People also have no control over what their health priorities are. For example, malaria is also a huge health concern in areas where trachoma or onchocerciasis are prevalent, prompting people to wonder why they should participate in a program that ignores what they consider to be their main health concern (Samsky, 2009: 24). Ownership and empowerment over development and health policies are not only morally and ethically justified but they have also been determined to be crucial factors for these policies to be more effective.

Thus, drug donations conceived as a “charity gift” are subject to heavy criticism, with companies behaving like Mauss’ “rich almsgiver,” and reciprocity absent from these interactions. The WHO seems to be aware of this issue. In cooperation with a number of other relief agencies, it published some “Guidelines for medicine donations,” which were first drafted in 1996, then revised in 1999 and 2010. They state that

The selection of medicines to be donated must be based on a sound analysis of needs. Their quantification must be done in close cooperation with recipients, and distribution must fit with existing policies and administrative systems. Unsolicited and unnecessary medicine donations are wasteful and should not occur. (WHO, 2011)

These guidelines are only recommendations. They describe good practices that should be encouraged but have not obtained the status of binding regulations. This may be because imposing strict and binding regulations on the practice of drug donation would be seen as contrary to the “freedom” that should inspire such a gift and its modalities. Regulation would also raise the problem of sanctions: what kind of penalty could be appropriate in a supposedly altruistic context, without endangering a practice that depends on the goodwill of donors? It can be noted here that if drug donations were understood according to a Maussian definition, one that recognizes that altruism is not the basis for gift-giving, we could maybe see stronger regulations. Nevertheless, the existence of these guidelines could be interpreted as a call to move from unilateral gifts of charity to cooperative gifts, or “sociation” gifts (Lordon, 2011).

Cooperation through donations: The building of alliances and defusing of conflicts

Such an evolution from “gifts of charity” to “cooperative gifts” is facilitated by the fact that drug donations are also cooperative practices. Cooperation among different types of actors is necessary for a drug to be distributed for free. At the very least, it involves a corporation and an NGO, an international organization, or a private foundation. The latter actors have a presence on the ground and public health knowledge needed to make the donation work. To design the Mectizan donation program, for instance, Merck turned to the WHO and to an NGO, the Task Force for Global Health. Even if we noted earlier that cooperation with beneficiaries tends to remain limited, a minimal level of cooperation has to be secured, and it tends to increase with time, in a “snowball effect” of cooperation. For instance, in the case of the African Comprehensive HIV/AIDS Partnership (ACHAP), concluded between Botswana, Merck, and the Gates Foundation, the Botswana government began to take a more prominent role 3 years after its launch in 2000 (Chabrol, 2014).

In The Gift, Mauss argued that gift-giving and the triple obligation to give, receive, and reciprocate transformed conflicts into alliances and built chains of reciprocity. Drug donations, by placing the distribution of drugs outside of the market, can be seen as a means to pacify the violence of market exchanges, due to restrictions in access to drugs especially.

In this domain, strong conflicts arose during the 1990s, with the HIV/AIDS pandemic and global protests on the prices of treatment. The negative effects of the TRIPS agreement on access to medicines were heavily criticized in a global campaign (organized by NGOs such as MSF, Health Action International (HAI), Oxfam, Act Up, and Consumer Project on Technology (CPTech)). The very well-publicized case of the “Pretoria trial” epitomized tensions on this issue. In 1997, 39 pharmaceutical companies attacked the South African government in the Pretoria court, disputing a law that in the context of a rapidly increasing number of AIDS patients authorized the Ministry of Health to issue compulsory licenses and to carry out parallel drug imports. The 39 plaintiffs (among which were all the “Big Pharma” companies: Bayer, Bristol-Myers Squibb, Glaxo Wellcome, Hoechst, Merck, Novartis, Roche, etc.) alleged that the law respected neither the TRIPS agreement nor the South African constitution. The whole operation was a public relations disaster. As the Wall Street Journal sarcastically emphasized, “Can the pharmaceuticals industry inflict any more damage upon its ailing public image? Well, how about suing Nelson Mandela?” (Cooper et al., 2001). The 39 plaintiffs ultimately realized that and dropped the case.

This context put access to medicines at the top of the world agenda, and the issue was a target of the 2000 Millennium Development Goals (one of the subtargets of the 8th goal read: “In cooperation with pharmaceutical companies, provide access to affordable essential medicines in developing countries”). And indeed, drug donation programs blossomed during the late 1990s to the early 2000s, although they represent only a small part of global efforts to foster access to medicines. Thus, like gift-giving during the potlatch and the kula, the giving of drugs marks the transformation of conflicts into alliances. The objects exchanged are used to forge social relationships and enhance trust. Mauss (1925 [1990]) described how, in ancient German societies, “it was by the form of the gift and the alliance, by pledges and hostages, by feasts and presents that were as generous as possible, that they communicated, helped, and allied themselves to one another” (1925 [1990]: 77–78). Drug donations mark a first step on the path to cooperation and one that can be lasting and spill over well beyond the scope of drug donations.

Gift-giving companies are included in chains of dependency and “the contracting parties are deemed to be in a state of perpetual dependence towards one another” (Mauss, 1925 [1990]: 82). For instance, Brenda Colatrella, who was in charge of the Mectizan donation program at Merck, realized once the program had been launched that “it soon became a constant effort to keep on track, and we learned we couldn’t just throw money and medicine at it and wash our hands of operations” (Levine, 2005: 64). This perpetual dependence has sometimes been institutionalized by the building of public–private partnerships. In global health, they have been blossoming since Dr Gro Harlem Brundtland—the WHO Director General—called for collaboration with the private sector in 1998. The UN Global Compact and the 2000 Millennium Development Goals also called for a global partnership with the private sector. Although drug donations are not a necessary part of every global health public–private partnership, they are still a significant way for companies to contribute (Guilbaud, 2015a). The form of a “public–private partnership,” although not precisely defined, creates interdependencies between actors, and depends on reciprocity through the division and sharing of tasks and responsibilities, the agreement on goals and values, and the design of accountability mechanisms.

Through their participation in global health public–private partnerships, corporations gained the status of partners in global health governance. They are recognized as actors one should cooperate with, and they act as co-producers of health policies. In partnerships, activities performed by private companies can be framed in terms of general interest. The success of the Mectizan Donation Program for instance is symbolized with a sculpture of an African child guiding a blind man placed in three places: in front of the WHO headquarters in Geneva, ⁴ in front of the World Bank in Washington D.C. and in front of the Carter Center in Decatur, Georgia (USA). These sculptures represent not only the contribution of the donation program to global health but also the cooperation between actors to achieve this goal. However, these new cooperative practices lead to a blurring of public/private and for-profit/non for-profit lines. We have seen a rearrangement of elements traditionally assigned to the public sector, the non-profit private sector, or the profit-seeking private sector, a phenomenon sometimes described as a process of hybridization (Graz, 2008; Guilbaud, 2015a).

This inclusion of private companies in the international health system is also part of a movement whereby the market economy appears less subordinated/accountable to other social orders. Indeed, international cooperation has developed around market mechanisms, which has legitimized corporate aims—namely, the maximization of profits.

As Mauss noted when analyzing the potlatch, gift-giving practices also demonstrate one’s capacity to accumulate wealth and power and are instrumental in establishing a status-hierarchy among persons and tribes. Corporate drug donations are not only used to defuse conflict and build alliances but also can be seen as a way for companies to participate in and influence global health.

A plurality of corporate interests? Conceptualizing corporations as complex actors

Thus, drug donations can help companies achieve different goals, and they might result from a plurality of corporate interests. What drives corporations in implementing drug donations? Studies in economic sociology and political economy have tried to determine what constitutes corporate interests and to tackle the issue of preference building and of the choice of strategies. Following definitions proposed by Cornelia Woll (2011), interests can be defined as “valued end goals,” preferences correspond to the hierarchizing of possible results of an action/an interaction, and strategies are the means used to obtain the best possible result (2011: 66). However, confusion between interests, preferences, and strategies remains frequent in the literature (Woll, 2011: 68). Briefly, we can say that materialists will consider that interests result from the objective distribution of material gains in specific contexts, whereas idealists will argue that interests are shaped by intersubjective beliefs, which also depend on the institutional context. Indeed, most analysis, building on the work of Hall and Soskice, emphasize the importance of historical and institutional frameworks (Hall and Soskice, 2001).

In the The Gift, Mauss acknowledges the complex relation between gift-giving and interests. Gifts are not entirely disinterested and, as we noted in the introduction, altruistic motives are not necessary. In the gift-giving exchange system of the Trobriand Islands for instance, Mauss (1925 [1990]) notes that

they still have a complex notion that inspires all the economic acts we have described. Yet this notion is neither that of the free, purely gratuitous rendering of total services, nor that of production and exchange purely interested in what is useful. It is a sort of hybrid that flourished. (1925 [1990]: 93)

Mauss seems also to differentiate between an “economic instrumental” interest and other kinds of interests. Especially, he distinguishes between Homo oeconomicus, that is, the man as an “economic animal,” the man of morality and duty, and the man of science and reason:

It is our western societies who have recently made man an ‘economic animal’. But we are not yet all creatures of this genus. […] Homo oeconomicus is not behind us, but lies ahead, as does the man of morality and duty, the man of science and reason. For a very long time man was something different, and he has not been a machine for very long, made complicated by a calculating machine. Moreover, happily we are still somewhat removed from this constant, icy, utilitarian calculation. (Mauss, 1925 [1990]: 98)

Even if Mauss does not further clarify the role interests play in gift-giving, his recognition of the existence of a plurality of motives for human action combined with his understanding of gift-giving as a “total social fact” (Mauss, 1925 [1990]: 100) can provide some insight on the conceptualization of corporations as actors and on the analysis of the interests that drive their actions.

First, the recognition of a plurality of interests makes it possible to go beyond the utilitarian model of the maximization of profits and results. Corporate interests are straightforwardly understood as maximizing economic gain, and in this regard, drug donations are part of a strategy to achieve this “valued end goal” (Woll, 2011: 66). For instance, they are used to benefit from tax breaks. This is especially the case in the United States, which might explain why US-based pharmaceutical companies stand out among the donors of pharmaceuticals (Guilloux and Moon, 2001). They can also be a way “to get rid of stagnant stocks without having to pay for their controlled and expensive destruction in their country of origin” (Pinheiro, 2008: 580). They are also part of strategies to enter foreign markets. For instance, in the case of the Glivec donation to fight cancer, Novartis donated the drug only if it was also recommended by local guidelines, which enabled the company to expand its paid market as well and stopped the donation when a generic manufacturer was authorized to produce the drug (Strom and Fleischer-Black, 2003). Drug donations also help protect patents, acting as a palliative for strong intellectual property rights, which are an architectonic feature of today’s drug market system. As Jeffrey L. Sturchio, a former Vice-President at Merck, puts it,

Doing well is a precondition to doing good: an enabling policy environment (including, for instance, adequate TRIPS-compliant intellectual property protection standards) is a prerequisite for a company to have the wherewithal to mount a major philanthropic program like the Merck MECTIZAN Donation Program. (Sturchio, 2001)

This line of arguments directly inspired Merck’s donation of antiretrovirals (ARV, drugs against HIV/AIDS) in Botswana, through its participation in the African Comprehensive HIV/AIDS Partnership. The partnership was formalized between Merck, the Gates Foundation, and the Botswana government in July 2000. The pharmaceutical corporation donates all ARV treatments that are necessary to treat HIV/AIDS in Botswana. By providing patented drugs, Merck dissuaded the Botswana government from using generic ones and from challenging its patents. Such programs are attempts to defuse attacks against TRIPS and its role in health inequalities.

Drug donations also help maintain some modicum of global social cohesion, so that social unrest does not jeopardize the drug market. As Marcel Hénaff (2003: 312) underlines, in modern capitalist societies, the gift also bears the function of maintaining or producing social integration. Gift-giving has undergone a process of moralization, whereby the rich have to give back to society to correct blatant inequalities that would otherwise threaten their existence.

On the market, drug donations are also used in a logic of distinction, to establish a hierarchy between firms in a competitive environment. In the words of Mauss: “To give is to show one’s superiority, to be more, to be higher in rank, magister” (1925 [1990]: 95). For instance, Merck would win the “most admired business” award from Fortune magazine for 7 years following the creation of the Mectizan Donation Program in 1987 (Hawthorne, 2003: 12), and the company is still lauded today in certain business spheres (Jackson and Nelson, 2004: 317).

Finally, drug donations can be part of a strategy to improve a corporation’s public image, which is useful both internally, toward its workforce (to motivate employees, to attract new recruits), and externally, toward its clients or the public authorities. As already mentioned, cooperation with other actors enables them to participate in global health governance structures, and it is also a sign of goodwill to avoid regulation.

All this explains the design of drug donations. The tight control over donation programs and the restrictions are justified to protect the company’s financial interests. This instrumental use of gift-giving is nothing new. As Godbout noted, there has always been an instrumental use of gift-giving practices by merchants. In the mercantile domain, the gift is used to facilitate the circulation of commodities (Godbout, 2000: 115). For instance, a merchant will distribute free samples of a product or will provide a gift when a product is bought to ensure that the client will come back, and so on. In this understanding, to give is to take a risk (not to receive anything back) but this helps establish trust, which will be useful for later market exchanges. Thus, the gift serves a function, to support market exchanges. However, Godbout (2000) also notes that this instrumental use of the gift is ambiguous, because if the merchant wants to take full advantage of his gift-giving, he has to be sincere, otherwise trust will not be established (2000: 115). George W. Merck, the emblematic Merck president from 1925 to 1957, says the same with his 1950 statement that would become the corporate motto: “We try never to forget that medicine is for the people. It is not for the profits. The profits follow, and if we have remembered that, they have never failed to appear.” ⁵

There is ample evidence that companies do not adopt a behavior that contradicts their own economic interests (Woll, 2011). However, how they interpret these interests depends on the historical and social interweaving of their relations with the public sphere and with their competitors. This leads to the conclusion that firms are “intentionally rational actors,” but that the content of this rationality is socially constructed (Woll, 2011: 31). This implies that actors will decipher their interests from their interactions with their social environment. And that is when we see the Maussian “man of morality and duty” and “man of science and reason” appear, alongside the homo oeconomicus (Mauss, 1925 [1990]: 97). A Maussian understanding of the gift can thus encourage us to “open the black box” of corporations by taking into account that they are made of individuals and that their individual beliefs and values matter (while they are co-determined by the historical and institutional frameworks).

Reducing corporate interests in donating drugs to an instrumental use of gift-giving might obliterate the fact that they are made of individuals trying to show that they “possess more than a tradesman morality” (Mauss, 1925 [1990]: 108). Drug donations are extremely important to make employees satisfied and to motivate them. When scientists at Merck found out that ivermectin (Mectizan) was not only useful as an antiparasitic for animals but also efficient against human river blindness (onchocerciasis), they felt a moral duty to continue their work and fully develop the drug. A failure to do so would have been seen as a failure to accomplish their first mission: to produce drugs that help cure people. It might have led to internal discontent and questions over corporate strategy. This is illustrated in Roy Vagelos’ comments, head of Merck’s Research division in the early 1980s, who supported the decision to pursue the development of Mectizan: “I was so new to the business world that I still thought of myself as a physician first, scientist second, and president of an industrial laboratory third” (Vagelos and Galambos, 2006: 2). As Henkel and Stirrat note, we do not need to interpret this as a denial of interests in gift-giving, or as something unrelated to Mauss’ understanding of the gift as characterized by a triple obligation. In modern Western society, the counter-gift can often be interpreted in an immaterial or religious way, such as reward after death (Henkel and Stirrat, 1997: 79). As we mentioned earlier, the fact that gift-giving holds society together and creates links between individuals is a defining element of the Maussian gift, whereas altruistic motives or the desire to “do good” are not necessary characteristics. However, this does not exclude them. Depending on the institutional, historical, and cultural frameworks, they might be included in gift-giving practices.

Thus, the Maussian understanding of gift-giving as a “total social fact” (Mauss, [1925] 1990: 100) can be inspiring to propose a relational analysis of corporations and the shared construction of corporate interests. I think this should also incite us to pay attention to power relations (i.e. which individual actors see their interests prevail in gift-giving practices?) and to take into account the importance of historical change.

For instance, it is interesting to note how the presentation of corporate drug donations has changed. Even if, as we have seen, gift-giving acts as a support tool for market exchanges, until the 1970s, corporate drug donations were presented as formally belonging to another sphere of corporate activity, and as promoting interests other than economic/instrumental ones. However, with the expansion of capitalism and market mechanisms as the basis for cooperation since the 1980s, the links between gift-giving and market exchanges have become more explicit. This “outing” was reinforced by struggles over intellectual property rights and protests over the actions of the pharmaceutical industry. The presentation of interests in philanthropic practices has evolved, and the legitimacy of economic/instrumental interests as the basis for philanthropic actions and drug donations has been enhanced. The term “philanthrocapitalism” has been used to describe this evolution of philanthropy, which now aims to apply corporate management practices and to mobilize the market to foster social change. The explicit focus of philanthropic activities broadens beyond social gain, to encompass possible financial gains and to become closer to those of market activities (Abeles, 2003: 189; McCoy and McGoey, 2011: 146).

As Lindsey McGoey notes, the claim that a business-like approach to philanthropy is new is false (McGoey, 2015: 15). Carnegie and Rockefeller were in that sense already philanthrocapitalists. However, today’s philanthrocapitalism is characterized by two features: its scale and its explicitness (McGoey, 2015: 17). Consequently, it is no longer necessary to try to hide the fact that instrumental economic interests take the foreground. This is an important ideological shift, one that blurs the formal distinction between gift-giving and commerce. To explain this shift, I think that, inspired by Mauss’ understanding of gift-giving as a “total social fact” and as relying on a plurality of human interests, we should focus on analyzing the role of ideas in shaping gift practices.

Implications for social justice theory and equal access to medicines

Yet, some ideas seem to be extraordinarily long-lasting in the domain of philanthropy. For instance, Michael Green and Matthew Bishop (2008), the two authors of a bestselling book on the merits of philanthrocapitalism, explain that

philanthrocapitalism describes at the macro level the ways in which capitalism itself can be philanthropic, working for the good of mankind. It is not just that, at its best, capitalism drives innovation which tends to benefit everyone, sooner or later, through new products, higher quality and lower prices. The winners of capitalism increasingly see giving back as an integral part of being wealthy. ⁶

This reliance on the goodwill of rich people and/or successful corporations, capitalism’s winners, seems to ignore the empirical reality of the last decade—despite an increase in the revenue of the riches and the benefits of multinational corporations, inequalities have widened, also in the domain of access to medicines. As shown in the first section of this article, drug donations remain an inadequate palliative. Such a statement also seems to bring us back to the debates surrounding the actions of the first philanthrocapitalists, Rockefeller and Carnegie. William Jewett Tucker, a theologian who criticized Carnegie’s philanthropic ambitions at the beginning of the twentieth century, declared for instance that there is “no greater mistake than that of trying to make charity do the work of justice” (quoted in McGoey, 2015: 11). Furthermore, philanthrocapitalism also ignores the fact that during the last century, numerous academic works tackled the issue of social justice and income redistribution and tried to answer the question of how society should distribute scarce resources among people whose claims are opposed and to determine with what impartial standard such a distribution could be effective.

In the fourth and conclusive part of The Gift, Mauss does not provide a theory of justice per se, but he elaborates on the issue of “morality,” the moral criteria that should preside to life in society, and thus shows how his theory of the gift can have implications for social justice. For instance, Mauss (1925 [1990]: 86) understands nascent welfare politics as some sort of “counter-gift” for the work of individuals, which would justify the implementation of social programs. Mauss argues in favor of a redistribution based on an individual’s contribution to society, that is, his or her work. But it is not a strict compensation, nor a mere insurance system, for

those who have benefited from [a worker’s] services have not discharged their debt to him through the payment of wages. The state itself, representing the community, owes him, as do his employers, together with some assistance from himself, a certain security in life, against unemployment, sickness, old age, and death. (1925 [1990]: 86)

Such a welfare obligation arises “from reciprocity and cooperation” (Mauss, 1925 [1990]: 89) and its justification for Mauss seems to occupy a middle road between egalitarian redistribution and charity.

Mauss’ understanding should prompt us to look for the “original gifts” that could justify corporate drug donations as counter-gifts. We can mainly distinguish two of them. First, drug donations can be seen as a sort of compensation for strong intellectual property rights which enable pharmaceutical corporations to make profits. Second, they could also appear as a compensation for the fact that pharmaceutical companies need and use people’s bodies to be able to develop drugs, especially in the South. Academic work on the sociology of global health, for instance, has shown how pharmaceutical corporations use Africans’ bodies to research on HIV/AIDS, even if drugs might not be made available for them once developed (this was the case in the ACHAP HIV/AIDS partnership for instance; cf. Chabrol, 2014).

But as we have seen in the previous sections, the problem is that drug donations are often inadequate counter-gifts. Thus, we are faced with the question of what an appropriate counter-gift would be for the gifts pharmaceutical corporations received, for instance, from political actors (who grant intellectual property rights) or the people (who lend their bodies)? What kind of gift would satisfy Mauss’ criteria of nurturing the social relation between the donor and the receiver, and not fall into the trap of charity?

It could be argued that the equivalent for Mauss’ development of welfare systems would be the existence of universal health coverage, a goal that is actually promoted by the WHO. The abstract universal goal might sound cosmopolitan. However, the WHO recommendations target the national level and mobilize mainly the State as the central actor, whereas pharmaceutical corporations act globally. So the implementation of universal health coverage would ultimately depend on the State’s capacity to mobilize resources, for instance, through corporate taxes. This is in line with a “political view” of justice, where the existence of justice obligations depends on the existence of (national) social political institutions (Nagel, 2005). To extend the same logic internationally would be utopian.

However, instead of following the letter of Mauss’ political speculations, we might try to stay closer to the gift analogy and imagine more realistic counter-gifts for the international level. If the point is to compensate those who suffer from the laws and policies that pharmaceutical companies benefit from, that is, people who are part of the exchange cycle, then counter-gifts should respect the reciprocity logic and affect the terms of this exchange cycle. For instance, this would be the case with the practice of differential pricing (when a company adapts the price of its product according to the purchasing power of a country).

Yet because of the centrality of reciprocity, The Gift cannot evolve into a theory of social justice that would address the issues of inequalities, rights, or access to resources. Differential pricing, for instance, seems to suffer from the same criticisms as more straightforward forms of charity. For all Mauss says, the closer we remain to the gift analogy, the harder it is to find a meaningful normative/ethical difference with charity. A gift, even when it is a counter-gift, always depends on the will of the giver. Even if it is perceived as obligatory, the roots of the obligation lie in reciprocity rather than justice. His theory aims at social harmony more than social justice. Reciprocity is a central mechanism of the reproduction of society, and as such does not provide space for change. Inequalities are not a problem as long as they do not put social cohesion, harmony, in jeopardy. This is particularly clear in potlatch-like systems, where every gift has to be reciprocated to establish a status-hierarchy: there may be redistributive consequences, but within the limits of a hierarchical order. Furthermore, the key issue of access to resources and the ability to use them (to be able to reciprocate) remains a blind spot.

Indeed, from the focus on reciprocity follows an exclusion of those who are not part of the exchange system, either because they do not have the capabilities or because they refuse to do so. For instance, for Mauss, in a welfare system, redistribution is based on work (“The individual must work. He should be forced to rely upon himself rather than upon others.” (Mauss, 1925 [1990]: 88)), which raises the question of people unwilling or unable to work. In the example of drug donations, what about people who do not “lend their bodies” to pharma companies? What about States who do not grant intellectual property rights?

However, there might be better resources for a theory of social justice in Mauss’ description of the kula. Whereas the potlatch stricto sensu focuses on the exchange at the expense of the people involved, the kula uses the exchange cycle to forge social relationships and enhance trust. This implies a recognition of the other, especially of the other as an equal partner in a social system. Such recognition might be seen as much better ground for redistributive mechanisms. And because the people are well aware that the exchange cycle goes well beyond the people they interact with (Mauss, 1925 [1990]: 37), such recognition could enlarge the moral community beyond the narrow circle of reciprocity. A consequence of that might be that instead of differential prices as counter-gift for some, all people would be perceived as having a right to access to medicines.

The Gift does not provide a theory of social justice, but Mauss’ understanding of gift-giving provides a powerful tool to look at the nature of relations at play in drug donations, to look for the “original gifts” that prompted corporate drug donations as a counter-gift, and thus to justify their replacement with more appropriate practices. In this perspective, to recognize the original gift would be the first step to set up criteria for adequate redistribution.

Conclusion

Understanding corporate drug donations through a Maussian lens can be fruitful, both empirically and theoretically. Mauss’ understanding of gift-giving is valuable in our case study because it emphasizes the power dimension of the practice, as well as its relational and systemic effects. While recognizing that the gift is a human practice rooted in a plurality of interests (whether of homo oeconomicus, of the man of science or of the man of morality), Mauss does not describe it as altruistic or benevolent, but as an engagement of the person (and of his or her community) that creates and perpetuates social links.

Corporate drug donations share many of these characteristics. They are about power and accumulation. They are used in many instrumental ways, to enhance corporate profits, to gain a foothold in global health governance, to establish a hierarchy between firms (who will get the “most-admired” business award?), to maintain social peace within the workforce, to ensure the stability of the intellectual property rights system, and so on. Through these different channels, corporate donations create and nurture global social links. But are they more part of a “kula” or of a “potlatch” exchange system? We can find elements relating to both types of gift-giving, but, most of the time, drug donations seem to be more akin to a kula-like system of exchanges, a system of social relationships and trust, within which to pursue conflicting interests. However, image rivalry between donating firms would count as more potlatch-like, for instance.

Of course, this use of the kula and potlatch comparison is artificial. They were specific historically grounded practices, and ones we see through Mauss’ interpretations. But the analogy is helpful to think about whether there could be conditions to ensure “good” corporate drug donations. Even if there seems to be an evolution away from long-term drug donation programs, seen as old-school and inefficient charity aid, there will almost certainly always be emergency corporate drug donations (which are not necessarily as short-term as the word “emergency” implies). If they are designed as kula-like exchange systems, they could ensure the perpetuation of peaceful cooperation at the global level. Drug donations, because they are material gifts, can also be a contribution of corporations to global health that can be more easily controlled. Furthermore, corporate drug donations should not fall into the trap of charity but ensure the autonomy of the receiver, who should both enjoy the freedom to give back and feel the obligation to do so. Finally, following Mauss’ insights, we might note that if it were recognized that gift-giving does not stem from altruism or goodwill, regulation of the practice might be easier. And if drug donations are recognized as being counter-gifts (part of an exchange system of gifts), it might free our imagination to design alternative, and efficient, methods to tackle global health inequalities in access to medicines.

Mauss distinguishes gift-giving from market practices, where the exchange of things tends to follow more explicit rules (contracts, prices, an easier way out of the relationship), a finite temporality, and a utilitarian goal (to maximize an economic interest). Gift-giving seems to be an encompassing practice, one that primes and holds society together because it nurtures long-term social links. However, we can argue that because there is no pure gift and no free gift, the domain of the gift and the domain of commerce can be intertwined through shared interests. And this interpretation is fruitful to make sense of corporate philanthropy in an era of “philanthrocapitalism.”

This can have three main theoretical consequences. First, we should always consider corporations as complex actors and realize that the micro-level of the individual matters. For instance, this might lead us to study how the individual gift-giving practices of employees find themselves embedded in organizational ones, and how these practices are transformed in the process. Second, the focus should also be on analyzing the role of ideas in shaping gift practices. If gift-giving is a “total social fact,” based on a plurality of human interests, it can nonetheless evolve over time. Gift-giving not only builds social relations and social order but also is constituted by them, can vary in forms, and can evolve according to socio-historical contexts and be shaped by ideas. Third, a proper understanding of the normative consequences of some of these ideas might take us beyond the scope of gift-giving and toward a theory of social justice.