Reviewed Book
Compound Solutions: Pharmaceutical Alternatives for Global Health. Susan Craddock, Minneapolis: University of Minnesota Press, 2017, 166 pp.
Susan Craddock’s Compound Solutions is a well-researched, thoughtful, and balanced look at a new player in the pharmaceutical industry: product development partnerships (or PDPs) that aim to develop new drugs for neglected diseases. The book delves into the world of drug development for tuberculosis (TB) to illustrate how PDPs may be, in Craddock’s words, “forcing a shift in the ontological mooring of today’s market-driven neoliberal pharmaceutical industry” (p. 5)—pushing it from an industry serving the global elite toward one serving the populations with the highest burden of disease.
TB kills nearly 2 million people every year, mostly poor people. Treatment for TB involves months of drug therapy with unpleasant side effects, and drug-resistant TB is a rapidly growing problem. A vaccine for TB exists, but it is not particularly effective and has only limited impact on transmission. Thus, better drugs and vaccines are needed. However, since the populations that suffer from TB cannot afford to pay high prices for drugs, there is little incentive for for-profit pharmaceutical companies that are accountable to shareholders to devote resources to developing new vaccines or therapies for TB.
The TB Alliance and Aeras, organizations largely created and funded by the Bill and Melinda Gates Foundation, aim ambitiously to create a new model of pharmaceutical development—one in which priorities are driven by burden of disease rather than by potential for profit. Compound Solutions is a critical examination of this effort, describing and analyzing these organizations and their collaborations with governments and for-profit pharmaceutical companies to develop new TB drugs.
Craddock’s work is informed by ethnographic research into the TB Alliance and Aeras spanning six years. She conducted 80 interviews with officials and scientists involved with efforts to develop new vaccines and drugs for TB. Craddock also attended a number of conferences and visited a vaccine trial site in South Africa. The result is a rich analysis of the workings of these organizations, one that understands both their moral economies and the compromises their employees must grapple with on the way to improved TB therapies. As an ethnography of the producers of drugs rather than the consumers, Compound Solutions provides an important and needed counterpoint and supplement to the large body of medical anthropological work focusing on the patients targeted by global health interventions.
This approach yields many interesting insights. As just one example, Craddock provides a fascinating and balanced analysis of why for-profit pharmaceutical companies sometimes choose to participate in tuberculosis PDPs, even when TB drugs are unlikely to ever be very profitable. Some engage in TB drug development as part of “Corporate Social Responsibility” programs, aimed at burnishing their image and motivating employees. Also, despite the likely very low profit margins of any TB drug, some companies think that the potentially high volume of sales may make such drugs worth their attention. Additionally, some pharmaceutical companies see TB drug sales as a potential way to get established in big markets like India, China, and Brazil with growing populations of potential users of their higher-profit drugs for chronic conditions like hypertension and cancer.
Yet, while Craddock takes drug companies’ internal logics seriously, she does not accept them uncritically. A real strength of the book—one that makes it a model for the anthropology of global health—is its balanced approach. Craddock does not let drug companies off the hook for ethically questionable or reprehensible practices. At the same time, however, she keeps clearly in view the importance of what these PDPs are trying to accomplish. The result is a rich analysis that eschews easy moral certainties in favor of careful attention to the complexities and gray areas that accompany global health interventions.
A particularly important example of the strength of this approach is Craddock’s exploration of clinical trials, found in Chapter 3. This chapter, which describes a trial for a TB vaccine carried out outside Cape Town, South Africa, is a significant addition to the anthropological literature. Quite unlike the clinical trials described by many other anthropologists, this was a trial designed to develop drugs to benefit some of the world’s poorest populations. Yet this does not mean that the trial is free from ethical gray areas. Craddock’s analysis of the community engagement efforts of this clinical trial, the “contingent ethics” of decisions about whether to provide interventions like nutritional supplements to the children enrolled in it, and the implications of failed trials are all fascinating.
Throughout the book, Craddock’s analysis is detailed and very dense, with a great deal of information about both the technicalities of drug and vaccine development and the organizational details of various institutional collaborations. This means, unfortunately, that the book would not be well suited for undergraduate courses, and might even pose a challenge to some graduate students. The notable exception is the introduction to the book, which provides excellent, clear, and accessible background information on the issues the book covers. Overall, however, the book is best suited for those with a keen interest in pharmaceutical development in global health.
Compound Solutions presents a great case to think with: PDPs are ethically complex, and Craddock argues that they are changing the landscape of global pharmaceuticals. This book, with its nuanced analysis that avoids easy moral certainties, is an important read for scholars interested in the role of pharmaceuticals in global health.