Very interesting essay by Kaushik Sunder Rajan entitled Pharmaceutical Crises and Questions of Value: Terrains and Logics of Global Therapeutic Politics that does a good job of tying the sorta odious practices of the health care industry we all know about to a value logic conception.
in this essay, I explore how the contemporary global terrain of drug development is constituted by different logics of crisis. I explore this terrain through an empirical focus on pharmaceutical logics and politics in the United States and India today, which are constituted, at the very least, by interrelations between multinational corporate interests, the local generic drug industry, neoliberal patient consumers, marginalized experimental subjects of clinical trials, and global civil society advocates for access to essential medicines. My argument is that the constitutive state of crisis experienced by all these entities (though in different ways and with different stakes) is a consequence of the playing out of structural logics of global capital and biocapital. These logics are constituted by the value systems of speculative capitalism; the instrument of intellectual property; the imperatives of the globalization of biomedicine; and the way in which health itself comes to be appropriated by capital as a source of value. In the process, I suggest that value in biocapital itself needs to be conceptualized.
If was particularly struck by the following:
To develop a concept of capital it is necessary to begin not with labor but with value.
—Karl Marx, Grundrisse
To develop a concept o biocapital it is necessary to begin not with health but with value.
—What Marx might have said if he were making an analogous statement today
Thus, consequent to the structure within which the research and development–driven pharmaceutical industry operates, there is a monopo- listic tendency that is enforced through patent protection, which has con- sequences for drug access, especially (but not just) in the developing world. In the process, one sees a fundamental shift away from the research and development model that has de”ned the industry for much of the past two decades. Pharmaceutical industries, it could be argued, function less and less as discoverers of new therapy and more like investment banks, control- ling, regulating, and betting on the %ow of capital. In the process, an indus- try that behaved in certain ways, in part, as a response to its location in the speculative marketplace ends up reinforcing, perpetuating, and participat- ing in speculation. This process of shifting corporate strategy in terms of “nancial risk calculus, I argue, results in the complete separation of value from considerations of patient needs or good health.
Indeed, the very definition of health is at stake and reconfigured in this process. Health is now understood in terms of what Joseph Dumit calls surplus health.) Health itsel becomes abstracted from healthiness and operates purely as potential for the generation of surplus value, in the manner that labor does when it becomes surplus labor in industrial capitalism. The shift away from a research and development–driven model of pharmaceutical development parallels a resolute shift in the understanding o health as surplus health; inversely, health has to be seen as a potential source of value if one is even to imagine making the kinds of speculative financial bets on it that one sees in this model of pharmaceutical development. Such a bet has nothing to do with healthiness or therapeutic efficacy;it is, rather, a bet on market size, market penetration, and the potential for market growth. It is a bet on therapeutic consumption—which, in order to be a source of surplus value, must be potentially greater than the amount of therapeutic consumption required to maintain healthiness. This creates a structure of crisis for patients.
The point here is that, once capitalized, there is no way that the pharmaceutical industry cant think otherwise, because,by the nature of its enterprise, this is an industry caught within a structure of contradiction. It generates value through the production and sale of therapeutics. Since therapeutics are designed to make sick people better and once they are better people stop taking the therapeutics, the pharmaceutical industry is rare in that its products, if they work, obviate their own necessity. Even more fundamental than the historically developed forms of crisis in terms of pipeline problems or patent clis, then, is this almost ontological structure of crisis that exists within the rationale of the industry itself—a rationale whose contradictions are exacerbated only by its location in a speculative market- place that demands constantly high growth. The only way that this can be countered is through the redefinition of disease itself, as something that is not an episodic state of abnormality that can be rectified through therapeutic intervention but is instead a constitutive facet of life itself. Hence, either disease is redefined as a chronic event, demanding lifelong therapeutic management, or therapies are developed as prophylactic interventions that need to be deployed even before the onset of disease. Both of these necessarily redefine health as surplus health.
Once this is understood, the logics of therapeutic consumption become entirely analogous to the logics of wage labor that Marx traced in industrial capital; surplus health becomes analogous to surplus labor; and clinical trials become analogous to machinery
Rather than reducing labor, machinery serves to increase value; machinery is always already operating in the cause of value, not in the cause of labor,and labor itself can be conceptualized only in terms of its potential to generate surplus, interms of surplus labor. Similarly, once clinical trials can show the potential for future therapeutic consumption, it becomes wasteful to not think in terms of maximizing that consumption—and hence also maximizing the trials that can provide the epistemic rationality for further consumption.
value can be increased if the price of drug development is reduced. This is best achieved by reducing the cost of clinical trials through outsourcing trials to the developing world.
Marx begins volume 1 of Capital with the question of value. He does so in an interesting manner. It is often assumed that for Marx value is composed of the triad of use value, exchange value, and surplus value. But in fact, in his analysis, this triad is not assumed; it emerges, analytically, in a particu- lar manner. Use value is the straw man in the analysis—it is the form of value that we already know is not what is expressed in capitalist relations of production, where value is realized through processes of exchange. Yet, crucially, Marx begins volume 1 not with a con%ation of exchange value and value but rather, precisely, by keeping them apart. “Value,” for Marx, is care- fully kept indeterminate and unde”ned through the “rst part of the analy- sis in volume 1, concerning money and commodities.
Partly, this indeterminacy is maintained because, eventually, Marx traces the relationship between value and what he calls surplus value—the always already inherent tendency of capital to constantly increase its own value. But in fact, the term surplus value is introduced by Marx quite late in his analysis, only in part 2 of volume 1, when he explores the transfor- mation of money into capital. In the entirety of part 1, which looks at com- modities, money, and processes of exchange, surplus value is not a category that is at stake.”
“Value,” then, serves two analytic functions for Marx. First (though chronologically, in the text, this comes later), Marx shows if one is considering capital, then value has no meaning unless it is surplus value—surplus is inherent to the ontology of capital itself. For money to be capital, it must have the potential for generating surplus within it—potential that, in the case o industrial capitalism, crucially is mediated by the exploited labor of the worker, and that, in both industrial and mercantile capitalism, is unleashed through the circulation of money and its exchange for commodities that are themselves circulated again for money repeatedly. Second— and this is fundamental to the very structure and argument of volume 1— value allows the commodity, which is always the product of specific and concrete human labor, to figure as abstract labor. If we make the BioMarx substitution on this assertion, we get that value allows the symptom, which is always the product of specific and concrete human health, to figure as abstract health. At the core of Marx’s critique of political economy is his insistence that value is an abstraction device.
In other words, in relation to money, value introduces the non- equivalence that is at the core of the transformation of money into capital. For money to be money, it must be a universal equivalent, engage in a process of exchange where what is paid is equivalent to what is received (whether that payment is wage for labor or money for commodity). But for money to be capital, it must precisely have the potential for nonequivalent exchange—the money that emerges from a process of circulation must be greater than the money advanced into it. Money is valuable only when it can simultaneously perform this contradiction; this contradiction is at the heart of the question of value;and value itself is defined by the ability of this contradiction to be constantly performed and naturalized. This can happen only when value emerges, also, in relation to the commodity, allowing a particular commodity to shift from being a particular, useful object made in a particular way through the employment of particular kinds o labor into being a generalizable mediator of exchange that can be expressed not in the quality of labor but simply in its quantity. This is precisely what happens when value appropriates the symptom—it allows a generalization away from individual, embodied questions o healthiness, qualitatively expressed, into epistemic, quantitative, mea- surable categories like biomarkers, risk thresholds, treatment times, and maximally tolerable doses. These things can be traded in terms of therapeutic consumption by certain people who have the capacity to liquidate their (now abstract) health in terms of money, and they require the experimental subjection of other people who have the capacity to be made bioavailable in order to generate the epistemic justi”cations for such liquidity. This appropriation has particular, historically specific and emergent, spatial and inter- subjective configurations, but the logic of this appropriation is inherent to the logic of capital and the definition of value.
One cannot understand this if one begins one’s analysis from health (just as Marx suggested one could not if one began one’s analysis from labor). One must begin by understanding value itself. And value in capital is a tricky beast. On the one hand, it is simply an attribute (something that a commodity has: its utility, its beauty, its ability to be worn or eaten; something that a symptom has: its presentation as disease, what it does to the body; something that money has: its ability to circulate, to mediate and measure other kinds of circulations, to quantitatively express circulation itself ). But on the other hand—and showing this is precisely Marx’s genius—value performs the various materializations and abstractions of those things that it is simply supposed to represent. Value is the abstraction through which equivalent exchange comes to generate surplus; through which specific, embodied labor can be signified as generalized, alienated labor; through which particular, embodied symptoms can be expressed as gener- alized risk thresholds that can be converted into capital through therapeutic consumption. To quote Marx:
In the circulation M-C-M both the money and the commodity function only as dierent modes of existence of value itself, the money as its general mode of existence, the commodity as its particular or, so to speak, disguised mode. It is constantly changing from one form into the other, without becoming lost in this movement; it thus becomes transformed into an automatic sub- ject. If we pin down the specifc forms of appearance assumed in turn by self- valorizing value in the course of its life, we reach the following elucidation: capital is money, capital is commodities. In truth, however, value is the subject [i.e., the independently acting agent] of a process in which, while constantly assuming the form of money and commodities, it . . . valorizes itself independently. For the movement in the course of which it adds surplus-value is its own movement, its valorization is therefore self-valorization. . . . By virtue of being value, it has acquired the occult ability to add value to itself.’)
I wish to suggest that the structure of crisis is contained within this particular property of value itself—as simultaneously material and abstract, attribute and subject. The particular historical, geographical, and institutional trajectories by which this crisis is made manifest is something I have attempted, in schematic fashion, to show here in relation to the pharma-ceutical industry. But unless we understand the genesis of crisis as residing in the value form itself as it gets appropriated by logics of capital (so that logics of capital themselves come to define what value means, in all of its material, abstract, symbolic, and agential manifestations), it is impossible to think of transcending the crisis simply through institutional responses.
Find it in the current issue of The South Atlantic Quarterly.