Interview with Susan R. Whyte

This is the sixth interview in the journal’s new “Conversations” section. Drawn from my broader project Interviews with Researchers from the Anthropology, History, and Sociology of Pharmaceuticals: Mapping Out the Area,¹ the following discussion features Susan R. Whyte. For an unabridged video version of the interview, visit the project website. I hope that readers enjoy this thought-provoking and fruitful discussion.

Rafaela Zorzanelli: If we look at some of the studies in the field of the anthropology and sociology of pharmaceuticals today, we can find research subjects such as lifestyle drugs (prescription drugs), the so-called epidemic use of psychotropics such as antidepressants, benzodiazepines, and opioids, and, from a different perspective, the medical use of cannabis and the microdosing of psychedelics (like MDMA and psilocybin) for treating mental disorders. Could you comment on or compare the similarities and differences between the issues that first inspired your approach and the current scenario in the field, with its new central topics?

Susan Whyte: Let me start by going back to how I developed this interest. And it really came out of a concern not with pharmaceuticals but with what might be called African medicines: herbal medicines, or what you call magical medicines. Initially, I was interested in all ways that people might try to alleviate misfortunes, which was mostly sickness, really. Medical anthropology didn’t even exist in those days when I started, 1969 to 1971. But I was interested in the ways people used ideas about cursing, about relations to the spirits of the dead and other kinds of spirits. Among those options for dealing with illness were African medicines. What interested me then was the contrast between the powers of a substance versus powers of relationships. So removing a curse or giving a sacrifice to spirits is a kind of relational action, you could say. Whereas using some kind of herbal medicine or medicine you got from a medicine specialist—that was a different kind of power, it was the idea that the substance itself had a capacity to transform the situation.

Then I began to see substances that people were using were synthetic substances, so penicillin, battery acid (this caught my attention and people were saying “well, yeah that’s one of the kinds of medicines that you can use to harm people!”), rat poison, and so on. From that came the idea about substantive power, the power in a material thing (versus other kinds of powers) could change the situation. I saw that relational power always involved other people. Usually some kind of ritual would be performed. And there was a kind of affirmation of relationships to the dead, to the spirits, to the senior relatives, whatever, that was involved in that kind of treatment, whereas the substantive powers of medicines were somehow more individual. I observed that there was a difference in the social consequences of different kinds of treatment. And then I wrote an article a long time ago called “Penicillin, Battery Acid . . .”¹ That got me much more into pharmaceuticals. And at that time, historically in Uganda, it became possible for me again to start working there. So I started going back to Uganda doing my fieldwork and what I found was that the scene had changed radically and there were all of these small drug shops that were opening up everywhere. It was a different situation than what I had studied in my first work from 1969 to 1971.

It was the late 1980s when I started going back, and there was the essential drug program and there was all this availability and variety of pharmaceuticals that had not been available before. My interest was very much on pharmaceuticals in general and the questions of “what are medicines, how to think about medicines?” It was very much about the small drug shops; about medicines as a gift; about sort of knowing somebody who could help you to get medicines; about easy availability of all kinds of medicines that should be prescription-only, but they were very readily available; and about the relation between the formalized institutions, the government, the health care system, the recognized private clinics that were registered, and so on. So it was also about the distribution of medicines and the channels through which people got them.

RZ: In the major field of drug studies, including biomedical and legal research, it is common to deal with polarization, such as licit or illicit, ritual or nonritual, natural or artificial, treatment/enhancement. Could you share with us some of your thoughts about the role of such polarization? Are they useful in the anthropology of pharmaceuticals?

SW: They are somehow useful, I suppose, as a point of departure, and they are useful if you want to contribute to policy making. Because also they are the kind of categories that policy makers work with. But I think that so often when you actually do fieldwork, you realize those decisions [or binaries] become quite fuzzy and a lot of times people don’t even know that this is a medicine that is prescription only because [it] is readily available, so the kind of legal niceties are not at all clear to them. I think also that even the distinction, say, between herbal medicines or alternative medicines and pharmaceuticals/biomedical for regulation [is] important.

Clearly our research subjects don’t make the kinds of distinctions that I would make. And I think that is sort of important work for anthropologists to do in terms of these sorts of categories: what’s legal and what’s illegal. The boundary is very blurry for lots and lots of people. I think that those distinctions are . . . we can’t ignore them, they are really important. But we have to look at different perspectives on them and how important they are to whom and why. In some ways I guess even early on, in that first book from 1988², that kind of difference between pharmaceutical and traditional or natural or whatever you want to call them was an interesting issue and the way that vendors of traditional medicines mimic the packaging and marketing techniques of those who were selling pharmaceuticals. So already there the relationship between the two I thought it was really an important research problem.

RZ: In one of your most recent publications, you wrote an interesting parallel between divination and biomedical testing. In your words: “Divination and biomedical testing are two important modes of seeking knowledge in African societies (p. 97)”³ (or practices of discovery, you added later). I would like to extend your idea a bit farther. Isn’t the biomedical rationale and its different procedures and rituals (screening tests, diagnoses, medical procedures, risk-reducing pharmaceuticals, treatment for presymptomatic or prediseases) quite simply the way this specific cultural system called biomedicine addresses the uncertainty of aging, falling sick, and dying?

SW: Yeah, certainly. And some people even distinguish between ceremonies and rituals—rituals having some kind of supernatural power. I don’t think we need to do that, but just the idea that we have some sort of fixed agreed-upon procedures, delimitation in time and place.

RZ: The anthropology of magic (and works by Bronisław Malinowski, Arnold van Gennep, and Victor Turner) teach us that rituals are usually performed in situations of uncertainty or in crises, providing an explanation of the events and offering ways of overcoming such crises. Are we—with our stimulants, tranquilizers, and pain killers—so far away from rituals and amulets?

SW: Probably not. A technology is, by definition, an intervention that wants to accomplish something. And I think that’s still very much what taking medicine is about. But maybe we should go further and ask to what extent it has just become a habit. I think there are certainly similarities between rituals and magical medicines in the old traditional studies from Africa and other places in the world, and they kind of use medicines to change something, to improve, to keep something in a good way. Maybe it’s good to conceptualize a bit differently. Still yes, having that component of regularity but because it’s not just one event, one off, which a ritual usually is. Then it’s a different sort of social phenomenon, I think.

RZ: I would like to turn to the discussion of “biosociality” and “biocitizenship.” What key considerations should be taken into account in order to make an anthropology that could fulfill these general concepts?

SW: I think it’s a methodological issue. If you do research through an institution, with, say, a patient group, you get one perspective on it. Whereas if you spend time in people’s homes and try to follow them in their everyday lives, you see how many other relationships are sustaining people. And it’s not easy to do that. The easiest thing is to go through a treatment facility or an NGO or a patient group. So researchers end up going through these institutions and organizations, or doing research online with virtual patient groups. So they get a keen picture of biosociality. Whereas if you approach from everyday situations, you’ll see that their relations with other patients or with treatment providers are important, but they don’t fill most of people’s lives. And in low-income countries where they don’t really have any kind of welfare services, people are so dependent on their families or their friends or their neighbors for getting through problems, the biosociality is less important than it might be in a country where you have great health infrastructure. So I think that there are methodological issues.

If you want to see medicines, and illnesses and treatment in the context of people’s everyday lives, their livelihoods, their resource situations and so on, getting beyond the clinic is really important. I think the original work on biosociality was done in Global North, in certain social conditions that do not necessarily obtain in parts of the population of other countries.

Where is it useful, the concept of biosociality? To me, one of the obvious places to look is the relation between a health worker and the patient or client. That’s a biosocial relationship that exists because of a disease. And it’s interesting to look at that relationship in terms of how much is it focused on the disease and the treatment and what other kind of personal interactions might be important there. And you want to look at different kinds of treatment situations, especially in a country like Uganda where in a local health facility you might know the practitioner.

In countries in Africa where there are lots of NGOs and donors, a biological condition becomes an opportunity. If you are blind, if you are deaf, if you are HIV positive, it might be an opportunity to get a link into a donor-supported project that would give you certain benefits that would then fit into your other social relations. So that’s also a kind of biosociality that’s more important in these low-resource settings in the Global South.

RZ: Medicines are paradoxical things. They allow a kind of autonomy because they don’t require the presence of a doctor. Even in their absence, all the biomedical knowledge is still there in that pill, reified, fetishized, combining at the same time the presence of biomedical knowledge and the absence of a representative of biomedical power. They do away with the need for a doctor, but still embody values, beliefs, and faith in biomedical science, so to speak. Could you please comment on this paradox of medicines?

SW: Medicines are paradoxical in another way. They can be both poison and curative. They give you control but they may put you under control. You may become addicted and feel that they are controlling you rather than you’re controlling them. Again maybe we have to distinguish different kinds of medicines because certainly some medicines are originally prescribed by a doctor whether or not you take them. Or whether you take them in the way the doctor recommended you take them is another matter. Almost any medicine depends on the autonomy of the patient in a sense—that it’s your responsibility, too. Take it or not to take it? And how to take it, and so on?

The paradox is that it seems to incorporate the knowledge, the prestige, in many ways of biomedicine; the expertise is there, then it incorporates it in a way which is kind of a blind faith for many others because we don’t have the scientific background to understand which kind of molecules these are what they’re actually doing and so on. Because we somehow have faith in the institution of biomedicine, we believe that the medicines will help us. I guess what is striking in many settings in the Global South is this combination of faith in biomedicine and distrust of the institutions that are supposed to be administering it. And you know, people say, many medicines are on faith, but they are still taking them. So I think that that’s actually a really interesting line for researchers. What is happening here that people still . . . Yeah, but is it faith in medicines or to what extent is it wanting to show that you care, that you’re doing something about it, that you’re concerned. Because I think that’s also a part of it. That you want to show you are trying to do something. Either showing you as a patient, showing the others that you’re trying to take responsibility. And trying to get over whatever it is you’re suffering from. Or else, intimate others showing that they care. And showing that they care by helping you have access to something that is expensive, that it’s hard to get, that has social value. And part of it is also, yes, that kind of faith in science. I think there are probably other things besides faith in science that give medicines their value for people and make them want to take it. But I mean, again it’s probably an empirical question in different situations, what is it about? And how is skepticism or faith or acceptance, value, created undermined whether there are different places in which people want their children not to be vaccinated for measles and so on, and I think it’s probably an empirical question in the sense that’s gonna differ in different settings. I mean, in northern Nigeria, polio vaccination had a significance that it doesn’t have in Denmark. So it’s a very complicated question, but I think that they need to be considered in different settings. So that we have a sort of nuanced set of answers for it.

RZ: How can we think about agency when it comes to pharmaceuticals in the context of low- and middle-income countries?

SW: I guess, as an anthropologist, one wants to respect people’s rights to choose, but personally I would want to see some restrictions on what they can choose and what they should spend their money on. It’s a fine line.

I’m very closely involved with families in Uganda who were struggling with various kinds of health problems which I always hear about. Because they always get in touch with me for help. And when you see situations where health workers are referring patients who come for “free” treatment and the government hospital referring them to go to a private laboratory across the road which is owned by the health worker, spend money on expensive scans or X-rays or certain kinds of tests—money they don’t have. Because they’re caring about the person who is sick, because respecting the authority of the health worker, they think somehow they have to get that money together. This is an unfortunate situation.

I think there should be some kinds of control on the freedom of choice. That’s where public health comes in. That’s where a sort of health education comes in. I guess I’m more reserved now in thinking about how people should spend their money then I was originally. Early on I was just interested in what people think or what are they trying to do. As I become more and more involved with them as friends, I probably tend more to advise a friend as I think I would do myself. Because I know some therapies are really expensive!

RZ: Paying attention to those healing systems seemed a very interesting way to address how herbal medicines, rituals, curses, amulets, spiritual healing, and pharmaceuticals could be put together in a melting pot of ideas about healing, cure, and disease. How has the concept of therapeutic pluralism played a role in your work?

SW: In those early days [when] medical anthropology emerged as a kind of subdiscipline, medical pluralism was one of the key concepts. It has to be recognized, it was really important from the beginning—that are different possibilities that you can try out, and in a way, the existence of therapeutical alternatives is necessary because one is probably not going to work. So the idea of therapeutic pluralism is absolutely fundamental to medical anthropology.

RZ: I would like to understand a bit better the idea of the Third World being “invaded” by Western drugs, or the idea of a “pharmaceutical invasion” (which is a term coined by Ivan Illich in 1977), which you have written about. I would like to explain my question. The idea of “invasion” suggests that the “Third World” has less access to pharmaceuticals and more to traditional medicines. So “Third World countries” are known not only for their poverty but also for their inequality and social and economic contradictions. Let’s take Brazil as an example. It has the largest black population outside Africa, and was the last country to abolish slavery (1888), with all the consequences that that entailed. It is a highly socially stratified society. When it comes to medicines and the health system, Brazilian biomedicine is marked by unregulated overmedication, yet many basic health services are not available to the poor population. It seems to me that the idea of “Third World” or “developing world” in your previous work has more to do with local societies marked by poverty and scarcity, where so-called traditional medicine tends to prevail (or is supposed to prevail). Could you comment something more about this idea of “invasion of Western” drugs in the Third World?

SW: A lot has happened since we wrote that introduction. Of course, countries like Brazil and India are now major producers of pharmaceuticals. The idea of invasion sounds like it was all an intervention coming from outside. Of course, it wasn’t that. There was a great interest on the part of many poor people and rich people in those countries in biomedical drugs.

In many places people compared qualities of pharmaceuticals with those of their indigenous medicines. But also, the ways in which local medicines began to be commodified on the same model was really striking. And people used to say local medicines are good for certain conditions like mental health conditions for which pharmaceuticals don’t work. But that is probably because these pharmaceuticals aren’t really available or the diagnosis is a problem, and so on, so traditional medicines are still appreciated and used for some kinds of problems. I think the idea of the invasion is outdated. At the time, new markets for psychopharmaceuticals were opening up in places like India. So we called it an invasion, though “invasion” is not a very good term because it suggests a force from outside that is overwhelming people rather than something that is being welcomed and marketed by nationals of those countries as a commercial opportunity. In these kinds of early reports, it wasn’t so much invasion, it was an appreciation, it was interest, it was appropriation. I think the term “invasion” was important because there was this critique of Big Pharma, that [it] was a capitalist enterprise, going to countries to find new markets. But maybe invasion is just too simple a way of describing it because it’s not some kind of external intervention, it’s something that lots of actors are involved in and have different kinds of interest in. The invasion maybe belongs to a kind of a political economy critique that was and still is important in anthropology, but the term is also too monolithic, I think. Because obviously, pharmaceuticals save lives and help alleviate all kinds of unfortunate conditions if you use them right, so it’s not just to think about the money-making aspects of it as an invasion. The sociologists like Illich wrote about the “invasion” and flagged it for researchers and policy makers. We’re still concerned about the concept, but the other thing is that the demography of research has just changed. Before, there were few social science researchers working on these questions, and now there are so many, and more specialized studies.

RZ: Even the idea of “Western drugs,” I understood it in the context but if you think, nowadays, if you’re taking a benzo, there are so many layers of meaning that comes to a user when he or she is taking a Western drug, that I would say that the therapeutic pluralism comes first, then the very origin of the medicine. I hardly could think about a “Western drug” in this pure sense.

SW: Christianity is a Western religion in Africa. Christianity is more African than it is Western. Are these pharmaceuticals Western drugs anymore? I don’t think so. They’re everybody’s drugs. They are really commodities in the sense of being common. You can start with language. So in language, there’s a difference. People use to say in Bunyole (eastern Uganda) “the medicines of the hospital,” but I don’t hear them saying that anymore. Because after medicines come into the drug shops and others come to the hospital, people don’t call them “European medicines” anymore. There used to be the difference between “African medicines” and “European medicines.” And you still hear people saying “African medicines” when they are talking about herbal medicines or some kind of mixture that’s locally made. But I don’t hear people calling pharmaceuticals “Western medicines” or “European medicines” anymore, because they are now everybody’s medicines. But that is, in itself, interesting if you want to do a historical study on how people’s perceptions of pharmaceuticals have changed through any given historical period.