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Pharmaceutical markets in India: Questioning "monopoly"  

Review by Stefan Ecks  

 

Pharmocracy: Value, Politics, and Knowledge in Global Biomedicine 

by Kaushik Sunder Rajan 

Duke University Press, 2017 

 

In Pharmacracy, Thomas Szasz (2001) writes against the appropriation of medicine as a tool of politics. 

Critical awareness should be fostered against all forms of medicalization and against state control of 

health. In Pharmocracy, William Faloon (2011) argues that the US healthcare market suffers from 

inflated prices because the FDA approval system is inefficient and needlessly restrictive. A radically free-

market approach to pharmaceutical regulation and pricing would, he contends, lead to better health 

outcomes overall. In turn, Kaushik Sunder Rajan's Pharmocracy (2017) "coins" the same term to argue 

that multinational pharmaceutical companies should be prevented from establishing "hegemony": 

"Pharmocracy is a term I coin to refer to the global regime of hegemony of the multinational 

pharmaceutical industry" (p. 6). The "appropriation by health by capital" (p. 7) should be stopped. The 

state should not retreat, instead he wants "democratic politics to seize the state" (p. 242; which "state" is 

not quite clear).  

 

Despite the general subtitle ("value, politics, and knowledge in global biomedicine"), the book is focused 

on India, the world's largest democracy and one of the world's largest producers of generic medications. 

Sunder Rajan's rephrasing of "pharmocracy" is a critique of multinational companies (MNCs) trying to 

establish market hegemony in India. Pharmocracy is less an examination of political processes than a 

critique of monopoly capitalism. The great monopolists here are multinational pharmaceutical 

companies. By "multinational," Sunder Rajan does not mean any company that operates in several 

countries with strategies for global market reach, but only companies based in "Euro-America." MNCs 



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that are headquartered in India are not considered multinational. This is in line with how the term 

"multinationals" is popularly used, yet it sits oddly with the fact that most of the big Indian 

pharmaceutical companies have also gone "multinational" in the past decade: Ranbaxy, DRL, Lupin, and 

Cadila have all expanded far beyond India. According to Sunder Rajan, Indian pharmaceutical companies 

exemplify a different logic of capital altogether, one that is not focused on monopoly but on a 

"postcolonial nationalist free market" (p. 154).  

 

Sunder Rajan holds that the Euro-American MNCs' "end game" (p. 158) is eliminating all competitors 

within a particular market. Securing patents is only a means to an end. However, it is quite clear that 

"monopoly" is not the final goal either, but profits and shareholder value. Monopolies secured through 

patents are just one means to maximize profits, even in Euro-American markets. Recent high-profile 

controversies, such as Turing Pharmaceuticals' price hike of Daraprim (a generic drug), show that pricing 

can be greedy without hegemony or patents (Deangelis 2016). Sunder Rajan discusses the capitalist 

appropriation of health as if discovering a profit motive in a for-profit industry was a radical insight. 

Striving for "monopoly" through patents is also hardly a new trait of the pharmaceuticals industry, yet 

the book does not deal in depth with changing legal, political, and regulatory opportunities for companies 

to be able to establish monopolies.  

 

Sunder Rajan has conducted a number of interviews for this book, yet most of the evidence for his two 

case studies (a clinical trial for a HPV vaccine and Novartis' attempt to get a patent for its anticancer drug 

Glivec) comes from published scholarship and grey literature, such as court documents.  

 

The HPV vaccine story on Merck's Gardasil has already been featured widely, both in popular news 

media as well as in major science journals such as The Lancet, Science, and Nature (e.g., Larson, Brocard 

& Garrett 2010; Bagla 2013; Kumar & Butler 2013). However, Sunder Rajan's sources are not 

sufficiently referenced in the book. The vaccine trial story, while noteworthy as a study in how a clinical 

trial can fail, does not illustrate the "pharmocracy" argument well. What emerges is not the hegemonic 

rule of multinational companies in India, but a messy implementation of existing standards and, at worst, 

an attempt by MNCs to get their drugs inserted into public health programs. Sunder Rajan repeatedly 

insists that there was a "scandalous" misconduct in the vaccine trial, leading to the death of a number of 

participants, but then deflates his allegations by saying that no clear links between vaccines and these 

fatalities had ever been established (p. 79).  



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The Glivec story, which takes up two full chapters, has also been told before. That Novartis' court case 

for a Glivec patent in India was about anti-evergreening provisions in the Indian patent law (Section 3d), 

or that Novartis' goal was not to profit from Glivec sales in India but to protect its extremely lucrative 

sales in Europe and North America, has all been said a while ago (Ecks 2008). An interview with an 

Indian hematologist adds details to how Novartis' Glivec Patient Access Program (GIPAP) was 

implemented, but confirms what we already know about the Glivec case.  

 

It is not without irony that Pharmocracy attacks corporations for making existing products look 

innovative in order to win market hegemony. 

 

References Cited 

Bagla, Pallava. "Indian Parliament comes down hard on cervical cancer trial." Science, Sep. 9, 2013. 

(http://www.sciencemag.org/news/2013/09/indian-parliament-comes-down-hard-cervical-cancer-trial)  

 

Kumar, Sanjay & Butler, Declan. "Calls in India for legal action against US charity." Nature News, 

September 9, 2013 (doi:10.1038/nature.2013.13700) 

 

Deangelis, Catherine D. "Big Pharma profits and the public loses." The Milbank Quarterly 94 (2016): 

30–33.  

 

Ecks, Stefan. "Global pharmaceutical markets and corporate citizenship: The case of Novartis’ anti-

cancer drug Glivec." BioSocieties 3(2) (2008): 165-181. 

 

Faloon, William. Pharmocracy: how corrupt deals and misguided medical regulations are bankrupting 

America - and what to do about it. Mount Jackson: Praktikos Books, 2011. 

 

Larson, H., Brocard, P., & Garnett, G. "The India HPV-vaccine suspension". The Lancet 376(9741) 

(2010): 572-573.  

 

Szasz, Thomas S. Pharmacracy: medicine and politics in America. Westport, Conn: Praeger, 2001. 

 



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Stefan Ecks, MA, DEA, PhD, is a Co-Founder of the Medical Anthropology Programme at the 

University of Edinburgh. He has carried out ethnographic fieldwork on health, healing, and medicine in 

India since 1999. A focus of his work are pharmaceutical uses, psychiatric practices, as access to health 

care for poorer people. Recent publications include Eating Drugs: Psychopharmaceutical Pluralism in 

India (2013).   

 

 

© 2017 Stefan Ecks 


