1 Introduction: A new interface - information communication technology and the globalising of social movements
There is a new interface within the dynamics of global organization. The technological needs of globalised capitalism have spawned a new information communication technology which has the capacity to enable the globalising of social movements. The all-encompassing attribute of web infrastructure permits the ready clustering of similarly placed marginal or vulnerable groups into globally organised social movements. Social movements of health product consumers are now visible with web technology enabling such consumers to readily research and interrogate scientific, medical and commercial product data bases. Whereas much of the discussion of the globalisation of technology has focused on the globalisation of capital and the "flattening" agenda of a uniform global business model, a diligent scan of the new distributed technology environment demonstrates excluded areas and excluded groups increasingly finding their own routes and action space within the globalising social discourse (Little and Grieco, 2004; Little and Clegg, 2005).
With the development of highly distributed global information technology, there has been a collective development of public communicative skill building upon the consumer movements of the seventies such as the National Campaign for Firework Safety and "fair trade" producer movements of the eighties [1]. Within the world of business, information and communication technologies have been developed to enable the close management of distributed resources and distributed action (Holmes, Hosking and Grieco, 2002; Little, 2004) necessary to the management of a global economy. The real time global monitoring of distributed activity transforms traditional principal/agent relationships: head offices can readily track in real time every detail of action within out-located and out-sourced production and service activities. The remote is directly monitorable and trust relations between principal and agent are no longer a substantial issue: this real time remote control of distributed resources is a new institutional business competence.
Critically, however, the remote is equally able to monitor the centre: the traditional panopticon relationship (Foucault, 1979) of the powerful monitoring the less resourced, which has been described in its electronic form above, is in fact readily reversible. The remote is not simply able to shadow and monitor the centre and the leadership which has historically been situated there - power is locational - but also able to globalize its record of leadership's activity and its interactivity with the remote. Historically, discourse was situated in local relations of power and such local relations of power necessarily distorted voice and record (Habermas, 1987): the advent of a global discourse form which is situated outside local relations of power invites a revisiting of old theories.
2 History in evidence - a new social business
The relationship between new information technologies, globalisation and social exclusion has become a focus for discussion amongst the major social theorists of the contemporary period (Castells, 1996, 1997, 2000; Giddens, 1999, Ohmae, 1995). Most take the shape of the technology and its social organisation within a neo-liberal economic framework as unproblematic: the "big design" of high technology systems determines the audience and the terms of access to a global discourse. The developed economies dominate the direction of development in these technologies.
However, the issue is more complicated for within the new connectivities and adjacencies delivered by these same technologies, small, collective, distributed design is providing a voice from those traditionally left outside the formal hierarchy of distribution. High technology - in a literal sense in the case of satellite based communication - is providing the last crucial link in connectivity. Global access is provided by a technology originally associated with top down surveillance and the Cold War military history of the space race and satellite development. The wired world can now be joined to the unwired world in a way which removes the significance of spatial separation [2], through highly distributed access to the information infrastructure critical to the functioning of the emerging global economy (Little, 2004).
The internet has become a strong communication home for social movements who use this space to communicate with memberships both permanent and fleeting - 'open source memberships' which mirror the networks of open source software production - and to shadow strong societal interests with weak ethical values such as 'big pharma'. This diffusion of skills and sensibilities along with the necessary access to infrastructure has allowed a reverse panopticon to be created, in which formerly peripheral locations can shadow the developments at the "centre" and can develop a capability set of their own that can be electronically inserted into the broader pattern. Pressures on ‘big pharma’ from wide-based social movements of the vulnerable are having their effect. The concessions made by pharmaceutical companies over the pricing of AIDS drugs in Africa represent a triumph of political pressure over legally defined intellectual property rights which undermines the logic of existing company strategies.
Before exploring the structure of these social movements, it is important to take stock of the business pressures faced by ‘big pharma’ itself. The global pharmaceutical industry offers a striking example of a breakdown of established models of research, development and cost recovery. Drug design and development takes place in a highly regulated environment. The high cost of drug development must be recovered during a time-frame constrained by licensing agreements while in most countries governments represent the largest customer and are interested in lowering the cost of acquiring new drugs.
The established production chain of the industry has been transformed by technical change. Small innovative biotechnology companies beyond the established pharma production chain are looked to for the key to a new paradigm of drug development, one which might include the agricultural production of pharmaceutical compounds via genetically modified plants. The advent of combinatorial chemistry means that vast libraries of potentially useful compounds have been created by increasingly automated processes. Specialist companies now offer these to the major pharma players. The testing of these compounds has become a major bottleneck – with, at the other end of this process, clinical research organizations (CROs) offering the infrastructure for the clinical testing of drugs prior to licensing for medical use. These trials may be conducted in low cost locations in developing countries and on populations which may not be regarded as a market for the potential product - and the business ethics of this stage of the process have increasingly become an area for internet based campaigns independent of the final price of big pharma's products [3]
For every 5,000 to 10,000 compounds screened by the testing process, only some 250 will become lead candidates for clinical trials [4]. Of these as few as five drugs will enter clinical testing, with only one likely to achieve approval for use at the end of the three phases of clinical trial. Much of the protected licensed period will have elapsed before this drug is sold into a market in which governmental and private medical insurers are becoming increasingly concerned about cost inflation. Once the protection expires, other cheaper manufacturing locations are able to produced generic substitutes for the original proprietary product.
The high attrition rates at every stage and the need for the recovery of vast costs means that companies are searching for increasingly elusive "blockbuster" products. There are failures in use and controversies over value, efficacy and cost. The world wide vice president of GlaxoSmithKline (GSK) was reported as claiming that the most drugs work on less that fifty percent of patients for a variety of reasons (Connor, 2003). In this context, strategies for reducing the costs of such uncertainties are sought. The strategies sought include the involvement of low cost manufacturers and the accommodation of the generic market in profit models and the use of brands to maintain the value of a drug in the face of generic substitutes. AstraZeneca introduced a variant of its successful Losec ulcer drug, one of the world's best-selling drug with $6 billion in sales in 2001, before the expiry of patent protection [5].
Global electronically-facilitated pharma production networks are emerging to challenge older integrated single company chains. However, this same global electronic technology has allowed the emergence of more transparent meta-governance forms (Grieco, Little and Macdonald, 2003) with the stakeholders now including both governments and regulators plus the ultimate end-users of the products. With the advent of globalised information technology, the drug development process is increasingly forced to accommodate the concerns of the ultimate stakeholders - the users of the drugs and those with the conditions and diseases targeted by global drug manufacture.
The activities of Big Pharma have been shadowed by campaign activists with devastating results for existing drug development strategies. Act Up represents the U.S. AIDS activists who demonstrated physically against pharmaceutical companies in the 1980s, and continue to monitor events there. The struggle has been archived on line [6] and debates have been voiced from within the affected regions of Africa. For example, an African Aids portal has been established with the sponsorship of the South African Government. The South African Treatment Action Campaign in turn targets government policies [7].
Other related AIDS issue campaigns mirror, connect and interact with the challenge to "big pharma" - both rape crisis intervention and the responsibilities of employers for the well-being of their employees are the target of other on-line campaigns [8]. This broad sweep social campaign around AIDS is greatly facilitated by the technology of hyper-links.
The result is that of the strong position of the pharmaceutical companies, based on enforceable intellectual property regulations, has been neutralized by essentially political demands for affordable access to the necessary drugs. A major concession was made in April 2001, when pharmaceutical companies withdrew a court bid to stop South Africa from importing and producing cheap versions of patented AIDS drugs.
While the model of intellectual property favoured by Big Pharma is being promulgated as a global standard through TRIPS (trade-related aspects of intellectual property rights) agreements and the WTO, the arguments driven by the AIDS crisis are being applied to a wider context. The Consumer Unity & Trust Society (CUTS), established in India in 1983 provides an analysis of the impact of the forthcoming TRIPS agreements on the price and availability of drugs [9].
At the centre, the use of drugs is also being monitored in this way. For example, the advertising claims by AstraZeneca on the increased efficacy of Nexium are being monitored and challenged on-line ][10. On 13 October 2002 a television broadcast on the anti-depressant Seroxat used the BBC web site to elicit responses to the programme from users of the drug. These are now incorporated into an article in the International Journal of Risk and Safety in Medicine available on-line in pdf format [11]. A follow-up programme " Seroxat: e-mails from the edge", broadcast on 11 May 2003 was promoted by the Seroxat Users Group web site. By the second broadcast the British Medical Journal web site was carrying an article attempting to broaden the issue to selective serotonin re-uptake inhibitors (SSRIs) in general as a class of drugs whose problems are outweighed by their benefits [12]. While the U.S.-based Alliance for Human Research Protection takes a different view of patient experience [13], the implications for the monitoring of the activities of Big Pharma remain the same: distributed technology has provided a monitoring and mobilization device which widens stakeholder participation. A meta-regulation by the wider stakeholder community has been added to the governmental regulation of Big Pharma's activities.
3 Reshaping and responding: new realization of capital
In this story of reshaping and response,two main challenges to Big Pharma in respect of the control of the supply and price of AIDS treatment stand out: and both are to be found in the developing world. The first is in South Africa where the activities of social movements of AIDS sufferers resulted in a defeat for Big Pharma.
· The Aids war began in South Africa. At the Durban world conference in June last year African sufferers denounced "medical apartheid" and called for universal access to anti-viral drugs. Most Aids victims are in the South, the medicines in the North. In Pretoria, on 19 April, 39 pharmaceutical companies that were suing the South African government took stock of the damage done to their image by their defiant defence of their patents and suddenly dropped proceedings. Their aim had been to show that South Africa's laws, designed to ensure an affordable supply of drugs to the country, contravened the TRIPS (trade-related aspects of intellectual property rights) agreements negotiated under the auspices of the World Trade Organisation (WTO) [14].
The second is found in the challenge of the government of a developing nation: the nation is Brazil. Brazil has not only successfully challenged the patent rights of Big Pharma but it has gained a place in transporting these benefits to other developing countries.
· Because of Brazil’s success pioneering AIDS treatment at home, it will oversee many details of these programs. That includes a transfer of technical knowledge in manufacturing generic antiretrovirals and overseeing their use in countries whose populace lacks adequate health care. The programs are part of Bush’s effort to spearhead AIDS treatment to the hardest-hit nations of Africa and the Caribbean through his recently approved five-year, $15 billion Emergency Plan for AIDS Relief.
For Brazilians, the joint agreement is the sweetest victory to date in the ongoing global effort to provide universal access to AIDS care and antiretrovirals to some 30 million people living in Africa and other developing regions.
Until now, the US has been strongly allied with big pharma in a tooth-and-nail fight with Brazilian officials to prevent generic competition in the AIDS drug arena. After failing to negotiate drug discounts from multinational patent holders, Brazil, Thailand and Cuba opted to manufacture generics.
What was at stake for big pharma wasn’t really the tiny AIDS market in Africa—which represents only 1% of the billion-dollar AIDS market—but the larger patent system. Makers of new products or processes are now guaranteed a 20-year market monopoly under a WTO Agreement on Trade Related Aspects of Intellectual Property and Public Health, or TRIPs. US trade officials feared that softening TRIPs’ rules for lifesaving HIV medicines in a pandemic would usher in generic competition for other products.
Undeterred, Brazil fought back, arguing that Article 68 of Brazil’s 1997 patent law allowed it to make generics to address its national emergency. These drugs—made only for its national AIDS program, not for export—do not break patents. In 1990, Brazil, the second-most populous country in the Western Hemisphere, had an exploding AIDS epidemic—average survival time was less than six months after a clinical diagnosis. Most citizens lacked access to HIV tests and drugs. In 1993, the private Brazilian company Microbiologics began making generic AZT, and in 1994, the state did the same, providing AZT free through its public health system. AZT prices fell dramatically. By 1997, the government was making ddC and d4T and within two years, other nucleosides were available. In 2000, indinavir was added, then nevirapine.
Brazil’s estimated savings on these last two drugs was $80 million, or 30% of total drug costs for the year. By the time of the US WTO challenge in 2001, AIDS drug prices had fallen domestically by 70%. So had AIDS deaths. The health system had saved $677 million, and freed up hospital beds. Armed with such positive, cost-effective results, Brazil was cast as a fiery David against the Goliath of greedy big pharma.
Four months after filing the complaint, the US dropped it. Brazil continued to up the ante, threatening compulsory licensing to negotiate sharp 40% and 65% discounts on patented antiretrovirals from Switzerland’s Roche and US-based Merck. Then in November, Brazil helped broker a victory for developing countries at the 142-nation WTO Ministerial Conference in Doha, Qatar. A new ruling guaranteed poorer nations facing national emergencies the right to practice parallel importing or issue compulsory licenses to import or make generic drugs [15].
Part of the reshaping and response story is clearly that Big Pharma and big governments supporting Big Pharma such as the United States have become aware of the vitality of the negative image they have invited by permitting the development of institutional structures which preclude the world's poor having access to necessary treatment. Depriving the poor of any chance of treatment in the worship of commerce raises very primary issues of social justice: and issues of social injustice which the collective of the vulnerable act to change and to subvert. Documentaries on the smuggling of AIDS treatment drugs over Latin American borders by the families of dying children are on view in the heartlands of wealth and viewers join in the journey of struggle for health to the death of a child: global information technologies replicate and amplify and retain in clear sight the consequences of high profitabilities.
Furthermore, there is a growing awareness in business that the end user has the ability to organize globally in respect of product markets. The advent of the AIDS crisis, in both developing and developed countries during the nineteen eighties led to campaigns and actions which have effectively achieved the political neutralisation of intellectual property rights. At a time when Western drug companies are challenging the legitimacy of generic drug production in India, the acquisition of patents covering the strain of wheat developed by traditional means for the production of chapatis has become an embarrassment for Monsanto (Ramesh, 2004). A model of intellectual property based simply on description of natural material, including sequences of the human genome, has meant that the potential innovation of traditional medicinal compounds from plants and the genetic modification of other plants as a means of drug production have become problematic. This may have been a step too far in the promotion of a hegemonic domain based on North American understanding, and indeed, the San people of South Africa have recently obtained a victory in ensuring their rights to profit in the sales of a slimming drug known to them indigenously and now moving into commercial production [16].
Whilst traditional indigenous 'remedies' are brought within the global commercial pharmaceutical ambit, wider consumer resistance to technologies such as Genetic Modification have problematised potential "sunrise industries" within the global economy [17]. However, the opening up of governance and metagovernance of the life science universe has had positive results. The rapid formulation and coordination of a global response to disease was demonstrated by the highly distributed discourse around SARS. The CDC Atlanta and the World Health Organisation provided information on the progress of SARS [18].
An overview of the threat and progress could be seen at the Globalchange site [19]. Both the US Department of Defense Global Emerging Infections Surveillance and Response System and APEC (Asia Pacific Economic Cooperation) web sites provide monitoring [20]. A world SARS map is available from the Indian company maptell.com [21] and the measures in place in Singapore, Taiwan and Australia, for example, could be compared with those in any other country ][22. Through these global tools, the space, organization and management of the disease's treatment and containment can be monitored and compared from any point.
Grid computing was utilised, as with the SETI at Home Distributed Screen Saver [23], to harness the spare capacity of networked PCs in the analysis of SARS data. On the negative side, an internet worm has already used SARS as cover for its propagation [24].
The level of global networking around the SARS outbreak in terms of alert and containment raises the issue of the appropriate structures for research and development into treatment regimes and products. To outprice treatment for highly infectious disease in a world of rapid global disease transmission raises global governance issues. There is a parallel to be drawn between the concept of a potential open networked model of drug development and the challenge to conventional proprietary software development from open systems development in information systems. The collective development and free exchange of software - the bazaar - has been contrasted with the top-down creation of the expensive proprietary application - the cathedral (Raymond, 2001). Information technology is an essential foundation of current drug development with its dependence on the combinatorial chemistry described earlier but information technology creates new and immediate conditions for the surveillance of the drug industry by the end users.
4 Vulnerability of centrality
· Phanzi, Pfizer, Phanzi!" "Get out, Pfizer, go!" At rallies they sing the old liberation songs, replacing the names of apartheid leaders with those of multinational pharmaceutical companies. On the streets they chant demands, no longer for the vote or a living wage or freedom, but for fluconazole and cotrimoxazole and nevirapine. Their leaders and organizers might well be human rights lawyers and healthcare professionals, but most of the foot soldiers of the Treatment Action Campaign (TAC) - which has spearheaded the campaign for affordable medicine for HIV-related illnesses in South Africa - are ordinary South African men and women, HIV-positive but too poor to afford the drugs needed to keep them alive [25].
· BIG Tobacco, Big Banking—and now Big Pharma? It seems fanciful to speculate during a week in which Pfizer reported profits, for its latest quarter, of $4.7 billion, that America's mighty pharmaceuticals giants might find themselves vulnerable to the political attacks that have tormented some of America's other large industries.
Yet the parallels mount. Like the tobacco firms and investment banks before them, drugs firms face a dynamic, grassroots movement, centred on the states and driven by powerful economics, that bypasses their well-financed defences in Washington, DC. Disarmed of their lobbyists and friends in Congress, they appear to have no compelling answer to these attacks. And their billions of dollars in profits, of course, are precisely what makes them such tempting targets [26].
The directness of communication and the randomness of much of the new communication adjacencies remove the historical buffers - tightening the loose couplings within the system (Perrow, 1984). As a result, hierarchical control over the management of self-presentation has been loosened and alternative paradigms have spread quickly. And not only within the world of developing countries, for within the U.S.A. state health systems are following the lead of individuals who have sourced their pharmaceuticals from low cost Canadian providers via the Internet, in the face of opposition from the federal government. The determination of image and identity is now more widely spread in its authorship: the resources of the traditional press and the organs of government are no longer the critical elements in the shaping of public form and face but are matched and often overtaken by the interactivity and 'mass' gossip of the world wide web. Creative flexibility is required in the rebutting and re-shaping of negative images by those who stand to lose on the public display screen. Text and images and video clips are harnessed in the recontextualisation (Metz, 1996) of the "damaging": similarly, those communities who have historically been negatively portrayed harness the technology en masse to recontextualise their own histories and space in place, organization and management. History is rewritten, past steps are recalled and distributed archives form new territory on the globalised kaleidoscope. The health behaviours of the poor are relayed and replayed with due weight on the barriers to wellbeing shaped in the frame of profit - the 'sickness' career of the young boy dying of AIDS due to lack of access to medication despite the high level of organisation of his kin network in its effort to source drugs for him is very visible indeed.
Recent examples of the strength of this process of global visibility are found in the Post-Hutton Inquiry environment in Britain (Hutton, 2004). Cabinet papers normally kept secret for thirty years were posted on the internet during the enquiry, along with the full transcripts of the evidence given [27]. This opening up of the political process via internet presentation permitted the global external audience to make their own assessments of the relationship of judgement to the detail of the evidence. The widespread view of the disjuncture between these in the British case found resonance in Australia where the equivalent debate ended in an apology by John Howard, the Australian Prime Minister. The narrow legal interpretation of Lord Hutton was subject to a broader political judgement, just as the narrow interpretation of intellectual property by Big Pharma was compromised by wider political moblisation. Through the technology the centre becomes the focal point of the reverse panopticon: through this transparency it becomes vulnerable and has to adjust and tailor its responses.
The same reverse surveillance is confronting the assumption of governments. An adjustment to distributed metagovernance is necessary when, for example, George Washington University offers an on-line archive of government documents obtained under Freedom of Information legislation [28] and the Global Policy Forum and the Institute for Public Accuracy attempt to redress the mainstream media's treatment of government assertions [29].
In the case of Big Pharma and global risks of disease, the visibility of profits and the transparency of the geography of access to treatment are charted and rendered immediate by virtue of social mobilization of the new information technology creating a new and unique vulnerability for those located at the centre of power and wealth.
5 Conclusion: the new structure of global challenges
The patterning of business and government in the context of globalised information communication technology and its use by social movements is already changing. Transparency and ease of information access produce a new structure of global challenges. The interactivity of the new information world has generated challenges at many levels. Suppressing information is now problematic whilst electronic interaction creates new grounds and technologies for surveillance.
The contest between restricting and revealing information has become in the modern period a more complex battle; we now have a ringside view of the reverse surveillance of the emerging surveillance state in its "war on terror" coupled with the open metagovernance of the global corporation. Open policy responses are demanded by these new phenomena in a context in which analysis can be no simple matter. What can be in no doubt is that with the interface between new information communication technology and social movements in the struggle with big pharma, we have a new pedagogy of the oppressed (Freire, 1972).
Notes:
1. See http://www.angelfire.com/co3/NCFS/campaign.html and http://www.eftafairtrade.org/Document.asp?DocID=33&tod=4167.
2. See the Amazonian SELF project at http://www.self.org/brazil2.asp
3. See http://www.commondreams.org/headlines03/0903-11.htm and http://www.global-campaign.org/bigpharma.htm .
4. For the debate on this situation from within the industry see http://www.forbes.com/asap/2002/1007/054_print.html and Bernard S. (2002) ‘The Drug Drought’ Pharmaceutical Executive 1 November 2002 at http://www.pharmexec.com/pharmexec/article/articleDetail.jsp?id=50753
5.Omeprazole is proton pump inhibitor (PPI) which inhibits the production of stomach acid. In order to renew protection a single isomer variant, esomeprazole, which is in fact the active version of the molecule, was marketed in 2002 as Nexium. However, the protection on this molecule relies upon a weaker process patent which allows its separation, the actual molecule is not protected as it exists in the original drug. See Robin (2005) and http://www.worstpills.org/results.cfm?drug_id=475
6. Actup sites can be seen at http://www.actupny.org/ and http://www.actupny.org/reports/milano.html.
7. See African resources at http://www.afrol.com/Categories/Health/he_msindex.htm, http://www.afroaidsinfo.org/DesktopServlet. The consequences of African action are described at http://www.brookings.edu/dybdocroot/views/articles/florini200309.pdf and criticism of South African government policy http://www.tac.org.za/
8. See http://www.speakout.org.za/medical/main.html and http://www.treat-your-workers.org/.
9. See CUTS at http://www.cuts-india.org/about.htm and their views on TRIPS at http://www.cuts-india.org/1997-8.htm.
10. See http://www.healthyskepticism.org/adwatch/au/2003/nexium/feedback.asp.
11. See http://www.socialaudit.org.uk/5111-006.htm) and the on-line International Journal of Risk and Safety in Medicine article in pdf format at http://www.socialaudit.org.uk/IJRSM-161-169.pdf
12. See http://bmj.bmjjournals.com/cgi/content/full/325/7369/910.
13. See http://www.researchprotection.org/infomail/1002/11.html.
14. See http://www.globalpolicy.org/socecon/develop/aids/2001/07lemonde.htm.
15. See http://www.aegis.com/pubs/amfar/2003/AM031004.html.
16. See http://www.raceandhistory.com/cgi-bin/forum/webbbs_config.pl/noframes/read/537.
17. See http://www.which.net/campaigns/food/gm/misc/gm_foodbriefing.pdf.
18. See CDC at http://www.cdc.gov/ncidod/sars/ and the WHO at http://www.who.int/csr/sars/en/. There is a German language site at http://www.pneumokokken.info/index.htm?/sars.htm.
19. See http://www.globalchange.com/sars.htm.
20. See U.S. DoD at http://www.geis.ha.osd.mil/ and APEC at http://www.apec.org/apec/apec_information_on.html.
21. See http://www.maptell.com/maps/webmap/world/worldsars.htm .
22. For example, Singapore at http://www.sars.gov.sg/, Taiwan at http://sars.doh.gov.tw/ and Australia at http://www.health.gov.au/sars/index.htm.
23. See http://www.wired.com/news/medtech/0,1286,58678,00.html. SETI at Home is at http://setiathome.ssl.berkeley.edu/.
24. See http://www.linuxsecurity.com/articles/security_sources_article-7162.html.
25. See http://www.thenation.com/docprint.mhtml?i=20010514&s=gevisser.
26. See http://www.accessmed-msf.org/prod/publications.asp?scntid=145200315797&contenttype=PARA&.
27. See http://www.the-hutton-inquiry.org.uk/content/evidence.htm for this material.
28. See http://www.gwu.edu/~nsarchiv/.
29. See the Global Policy Forum at http://www.globalpolicy.org/ and and the Institute for Public Accuracy at http://www.accuracy.org/.
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