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‌Halting the ‘forced march’: The ups and downs of Chad’s integration into global pharmaceutical markets

‌Ilyass Mahamat Nour Moussa

On Tuesday, 3 September 2019, the Chadian pharmaceutical market found itself with a new World Bank–funded laboratory for the analysis of the quality of industrial pharmaceuticals. Its inauguration was a solemn event attended by Chadian officials and representatives of the World Bank at the premises of the Centre de contrôle de qualité des denrées alimentaires (CECOQDA) – the French expression designating the Centre for Food Safety – where the laboratory was established. The Chadian press showed up to cover the ceremony, which was broadcast on national television to introduce the population to the facility’s various technological analysis instruments. Hissein Tahir Sougoumi, Chad’s secretary of state for the economy and development planning, declared, ‘Chad has just been equipped with strong, independent capabilities in the fight against falsified medicines’. He justified the increase in medicine control by the weakness of the pharmaceutical supply system.

The mention of ‘falsified medicines’ in his speech was significant of the government’s efforts to act on the recommendations of international organisations to secure pharmaceutical markets. In this regard, the creation of the laboratory was more generally indicative of the government’s alignment with a global model of effective pharmaceutical management, promoted by international organisations such as the World Bank, and materialised by the deployment of regulatory and safety mechanisms. At first sight, this model could be described as an ongoing effort to consolidate and strengthen pharmaceutical supply chains at global and national scales. But the meaning of ‘consolidation’ and ‘strengthening’ should not be taken for granted, as securing the circulation of medicines in the Global South has also been identified as a key strategy of Northern companies and countries to assert their hegemony and dominance over global pharmaceutical markets (Baxerres 2015; Hornberger 2018; Quet 2022).

In this chapter, I discuss these complex articulations between the global models, their supposed imposition, and their local implementation. I show that the implementation of Chad’s laboratory is not simply the replication of a dominant model of pharmaceutical control in order to comply with global norms. To do so, I build upon a vast literature dedicated to the social study of pharmaceuticals in Global South countries. Some of this literature has analysed in depth the weight of control and regulatory operations upon medicines in pharmaceutical markets as they pass through various stages (Desclaux and Lévy 2003; van der Geest 2017; van der Geest and Whyte 2003; van der Geest et al. 1996). It has also offered a different reading to the circulation of medicines within the healthcare system, based upon several studies in Sub-Saharan settings (Desclaux and Egrot 2015; Fassin 1986, 2000; Peterson 2014; Whyte 1992; Whyte et al. 2002). In continuation with this scholarship, I highlight some of the ways in which actors located in a Global South country appropriate and circumvent a system designed to secure the flow of medicines (Quet et al. 2018). I demonstrate that the integration of Chad in global pharmaceutical markets is largely driven by power asymmetries between the North and the South. But I also show that if Southern governments are generally poorer, need more external financing, and are therefore more dependent on outside sources than their Northern counterparts, this does not mean that the financial flows that come their way will force them to do what funders want. The social actors, in governments as well as in the private sector, understand the rules of the game and know that they need to respect them to keep playing, but this does not necessarily mean that they will follow them blindly.

Hence, I want to nuance the idea that the ‘forced march’ initiated by the standardisation of regulatory work on the Chadian pharmaceutical market is solely a top-down process where local actors do not have room for manoeuvre (Radnóti and Moreau 2000; Rawicz and Chédaille 2011). Analysing how technical tools and regulatory frameworks are implemented in Chad through the case study of the creation of a national control laboratory helps us question the idea that external funders are omnipotent in shaping pharmaceutical markets and medicine flows in one country. This case will be helpful for thinking about and reflecting on how Global South players are anticipating, but also appropriating, repurposing, and circumventing, international organisations’ recommendations in order to fit their own needs.

I draw on empirical data collected during various field missions carried out in N’Djamena (Chad) between 2020 and 2023. During eight months of fieldwork, I held 50 semi-structured interviews with individuals directly involved in the creation and implementation of the laboratory, as well as members of international organisations, the pharmaceutical regulatory authority, and wholesale distributors. I also carried out direct participant observation at the medicine quality control laboratory in N’Djamena. As the laboratory was closed to the public, all my initial attempts to obtain information about its funding and its actual or supposed operation failed. Later, I got access to the laboratory through an acquaintance who worked as the head of food quality control at CECOQDA. Thanks to him, I could contact the manager and the seven other technicians of the laboratory. Throughout my meetings in the laboratory, I aimed to observe the actual practices of the technicians and understand how technical systems were set up for drug control operations. During this immersion in the laboratory, I created a trusting environment with my interlocutors by listening to rather than intensively questioning them, which helped me capture nuanced information that might not be obvious through more directive or structured enquiry methods.

The chapter is structured as follows. In the first section, I show how international organisations have played and continue to play an essential role in the global integration of the Chadian pharmaceutical market by supporting a specific approach to the securitisation of medicine flows. However, the Chadian state is far from being a passive recipient of global funding flows, which I show in the second section based upon the presentation of the SWEDD project – a project that local actors have diverted to suit specific needs as much as they have answered to external demand. Sections three to five then detail my argument regarding local adaptation by explaining how the pharmaceutical control tools are circumvented, diverted, and appropriated by the lab technicians, reflecting some of the dynamics of technoscientific globalisation ‘from below’.

International organisations and the securitisation of pharmaceutical markets in Chad

Chad has been engaged for several years in (re)building its national pharmaceuticals market, with the support of international organisations such as the World Health Organisation and the World Bank, among others. The World Health Organisation has played a primary role in the reframing of Chadian pharmaceutical markets, notably through regional initiatives. In May 2005, it funded the organisation of a workshop dedicated to the creation of a regional pharmaceutical policy that gathered the representatives of Central African Economic and Monetary Community (CEMAC) pharmacies in Yaoundé (Cameroon).1 This led to the elaboration of a pharmaceutical policy launched in 2014 and shared by the six member states (Cameroon, Central African Republic, Congo, Gabon, Equatorial Guinea, and Chad). The WHO acted as guarantor of this initiative to resolve dysfunctions in the various pharmaceutical systems by standardising the rules and functioning of pharmaceutical markets. In addition to these standardisation efforts, the organisation encouraged the regulation of markets at a regional scale. It organised training geared towards health centre pharmacists and journalists (on issues pertaining to pharmaceutical regulation), and contributed to setting up a network of journalists ‘Amis de la pharmacie’ (Pharmacy’s friends) for the fight against substandard and falsified medical products. The organisation has also been advising the implementation of significant regulatory measures in the CEMAC area through multiple initiatives, to such a point that, according to a WHO representative, the Central African community has become a benchmark.

Though at a different scale, the World Bank has also been one of the main organisations contributing to the revamping of the Chadian pharmaceutical market. Its implication in the Chadian pharmaceutical field goes back to 1994, when the bank funded the setting up of the Centrale Pharmaceutique d’Achats, the pharmaceutical procurement agency. More recently, it funded in 2019 the national pharmaceutical quality control laboratory studied in these pages. This contribution to pharmaceutical development is part of the activity of the bank in Sub-Saharan Africa. During the same period, it financed a similar laboratory in Mauritania and several initiatives to secure the flow of medicines in East Africa. Since 2022, there have also been joint initiatives between the bank, the West African Health Organisation (WAHO), and the United Nations Population Fund (UNFPA) to set up a system for controlling the flow of cross-border medicines. This web of relations between health actors financed by the World Bank has led to the creation of a subregional network of National Medicines Quality Control Laboratories (NMQCLS) in the Economic Community of West African States (ECOWAS), and additionally in Mauritania and Chad. The UN agency (UNFPA) and the subregional institution (WAHO) not only created the network but have also been actively involved in training Chadian laboratory staff and are even planning to launch a programme to monitor the percentage of non-compliant and falsified medicines.

As shown above, although the WHO and the World Bank are the most visible players, the project of (re)construction of the Chadian pharmaceutical market has involved multiple other organisations and has been unfolding at various levels in the field, starting with the activation of a former project to build a medicine manufacturing plant, which is still underway; the plan to set up a pharmaceutical regulatory authority; the creation of a medicines quality control laboratory; the opening in 2011 of a pharmacy department at the University of N’Djamena; the revitalisation of the drug commission; the training of pharmaceutical inspectors; the establishment of a health police force; the imposing of medicine traceability on private players; and the organisation of regular meetings between health players on medicine-related issues.

Beyond their diversity, one important aspect of these organisations’ engagement with Chadian pharmaceutical politics has been their emphasis upon speed (of change) and security. One example was given in 2019 by the organisations, via the Ministry of Health, of a national meeting on the topic of pharmaceuticals in N’Djamena, with exclusive funding from the WHO. The objective of the meeting was to advance an essential medicines policy and to align with the standards and guidelines recommended by the WHO in the field of pharmaceutical procurement and regulation. The WHO representative in N’Djamena asserted on this occasion that there was a significant discrepancy between the realities of the Chadian pharmaceutical market and the objectives of his institution. He pinpointed the slow pace of progress in the Chadian pharmaceutical market towards the WHO’s objectives. In order to make up for this loss of time in terms of legislation and regulation, it was necessary to speed up the improvements. He also suggested that health professionals and the Chadian government should move forward the harmonisation of the legal framework to combat substandard and falsified medicines (MQIF), establish a medicines regulatory agency or authority and a health police force, accelerate the MEDICRIME membership process and set up a national medicines quality control laboratory. His speech, both emphasising the need for more pharmaceutical security and the importance of acting fast, was revealing of the priorities set up by the WHO for Chad.

How can this drive to secure pharmaceutical products on the Chadian market be explained? Part of the answer is found in an interview conducted during the summer of 2021 in N’Djamena with managers of Laborex Chad, one of the major wholesale distributors of the Chadian pharmaceuticals market.

Some American companies refuse to sell us medicines because they feel that safety conditions in Chad are unreliable. By safety, we don’t just mean quality control of pharmaceutical products, but a whole process that consists in protecting Chadian products and consumers against risks.

From this interview with my interlocutor, it appears that safety and security are strongly emphasised by pharmaceutical industries. To import industrial medicines into the pharmaceutical market, certain laboratories require specific guarantees from Chadian wholesale distributors. This requirement by some pharmaceutical companies is a product of market normativity. Since 2020, some wholesalers have been reorganising their operations and establishing warehouse units that meet pharmaceutical companies’ criteria, such as maintaining a temperature below 25°C in the warehouses and developing a traceability system for the distribution of medicines on the local market. This sums up the vision of the external actors involved in this new reconstruction of the local pharmaceutical market. Refusal to comply with this injunction from the pharmaceutical industry could exclude a wholesaler-distributor, or at least interrupt their partnership with a pharmaceutical company.

Chadian stakeholders have described this framing of the pharmaceutical market regulatory work by international organisations as ‘extreme regulation’ and as a ‘forced march’ imposed on a country that has depended on medicine imports since it acceded to national sovereignty and where the pharmaceutical regulatory system is still characterised by many shortcomings. The expression ‘forced march’ refers to the various reforms of the pharmaceutical system that Chad has undertaken to comply with the requirements of international organisations, from the amendment of the pharmacy law to the creation of a medicines quality control laboratory and the requirement for pharmaceutical products to be traceable to wholesale distributors. The forced march is seen by multiple Chadian actors of the pharmaceutical sector as an obligation to drastically change practices, with no possibility of turning back, in order to achieve as fast as possible a goal defined externally. Through regulation at all costs, international organisations, with the support of a few national players, would seek to control industrial pharmaceutical circulation.

Today, several technical and financial partners are intervening in the Chadian pharmaceuticals market through various sanitation projects, which increasingly resemble a drive to control the circulation of medicines. The measures used by Chad’s partners and their discourse around the issue of safety seem somewhat exaggerated to me. (Interview with a senior health technician and manager of a pharmaceutical depot, N’Djamena, summer 2022)

This excerpt from an interview with the manager of a pharmaceutical depot in N’Djamena highlights the differences between the international organisation’s framework and local actors’ considerations regarding the security of industrial medicines in the Chadian pharmaceutical market. The rhetoric of security as put forward by the organisations is not universally accepted on the ground. Local actors even see it as a form of domination exerted by organisations such as the World Bank, the World Health Organisation, and other international institutions, all advocating for the securitisation of flows and, by extension, protecting the interests of large Northern pharmaceutical firms.

At first sight, it thus looks as if Chad’s pharmaceutical policy is largely dictated by international institutions based on global standards and through the implementation of technical devices. However, I show in the following section that the implementation of these standards is filtered by the local actors, who have agency in using development funds and setting up global norms.

‘Diverting’ global development funds: The establishment of the laboratory

The complex articulation between the standardised models promoted by international organisations and the reality of practices can be better illustrated through the history of the national laboratory for quality control. Building a national laboratory for the quality control of industrial medicines requires funding, something the Chadian state mostly lacks. However, African states often host development programmes that are well endowed with finances, as in the case of the regional initiative for Sub-Saharan Africa Women’s Empowerment and the Demographic Dividend (SWEDD), notably supported by the United Nations and the World Bank. The initiative was launched by the Sahel countries (Burkina Faso, Côte d’Ivoire, Mali, Niger, and Chad) in 2015 against the backdrop of multiple crises (humanitarian, security, and environmental) affecting this part of the African continent: weak state institutions, corruption, poor governance, and ethnic tensions exacerbated existing problems in the Sahel region. The combination of these multiple crises had initiated a vicious cycle of mutually reinforcing poverty, insecurity, political instability, and forced displacement. This was the context in which the SWEDD project was born and was subsequently supported by international institutions, first and foremost the World Bank. Through its International Development Association (IDA), the World Bank provided US$376 million, bringing the total funding to US$680 million for all the countries concerned with the project. This brings us to ask: given the scope of the SWEDD project, initially designed to support women in a context of multiple crises, how did the World Bank end up investing in the Chadian pharmaceutical market through it?

The SWEDD project, which was instrumental in setting up the medicines quality control laboratory, included a health arm to meet the demand for reproductive, maternal, neonatal, infant, and nutritional health products and services (SRMNIN). This arm mobilises significant resources on the ground, focusing on the health of women and infants. It develops programmes to improve access to maternal health care, such as prenatal consultations, skilled birth attendance, and postnatal care, and initiatives to promote family planning and reproductive health. The health arm of the SWEDD project also addresses issues such as sex education, early pregnancy prevention, sexually transmitted diseases, and HIV/AIDS. It incorporates nutrition-related interventions to combat malnutrition among women and children and to build the capacity of local communities to take charge of their health. This includes training community health workers, providing access to essential medicines, promoting hygiene, and supporting community-based disease surveillance systems. The health arm furthermore contributes to strengthening health infrastructures by renovating and extending them, particularly in the most remote and vulnerable regions. It is apparent from this description of the project that, although it did have a ‘health’ component from the outset, this did not include frameworks for securing the flow of medicines, which would subsequently receive World Bank support. The involvement of international institutions such as the World Bank has since been growing steadily within SWEDD, revealing a contradiction with the project’s initial objective of combating poverty and empowering women.

Through its health infrastructure development arm, the project financed the establishment and equipment of a quality control laboratory for medicines under the supervision of the Pharmacy and Pharmacopoeia Department of the Ministry of Public Health. Initially, the aim was to facilitate women’s access to essential medicines. However, a subsequent shift was apparent in the project’s objective towards the fight against falsified medicines, leading to a quality control laboratory. According to the person in charge of the health component of the SWEDD project, ‘it was the Ministry of Public Health that brokered the project and expressed the need to equip a laboratory theoretically created by the Chadian state, but which lacks everything required for its effective operation’. While this comment seems to indicate that the laboratory project was born out of a need expressed by Chad, it is significant that such a need had been embedded in the global context of the world’s pharmaceutical market for several years. We thus must nuance the idea that the Chadian state ‘diverted’ the funds; it did something not initially expected by their funding provider but nothing that went entirely against their interest and logic, as explained by the person in charge of the health component of the SWEDD project:

Today, there’s enormous pressure exerted by pharmaceutical companies worldwide. This weighs on wholesalers in terms of securing pharmaceutical products. Several pharmaceutical companies don’t want to trade with countries that don’t set up an effective monitoring system, and so Chad wanted to comply with this so that it could continue importing medicines.

This quotation confirms that in addition to the health activity developed by the SWEDD project and the World Bank’s financing of the laboratory, Chadian authorities have committed to securing the country’s pharmaceutical supply to meet the requirements related to the globalisation of pharmaceutical markets.

By ‘asking-agreeing’ to set up an industrial medicine quality control laboratory on its territory, Chad was trying to respond to the WHO’s request to control the flow of industrial medicines within its borders. Two factors in particular explain why the Chadian government mobilised in favour of this installation. The first concerns the knowledge produced regarding the Chadian market: several reports from the Ministry of Health indicate that the black market for medicines has a supply and distribution capacity ten times greater than the official market. The Chadian state thus seeks to limit potential crises related to the consumption of unauthorised medicines and emphasises a public health issue, in line with the recommendations of international organisations. This move is supported by local healthcare professionals and some wholesale distributors. For these distributors, the laboratory installation would slow down the unofficial trade of medicines and consequently provide an opportunity to sell more medicines in the pharmaceutical market. But the second factor is mostly financial: in setting up the national drug quality control laboratory, the Chadian state gave a sign of good will that allowed it to attract funding from World Bank and the WHO, in order to invest more broadly in other sectors. In that perspective my field observations show that the Chadian authorities not only answer to ideological and normative public health pressures, but they also navigate through external financial constraints in order to achieve their own goals. However, even though the industrial medicine quality control laboratory could now monitor the flows, local actors in the pharmaceutical system would follow rationales and interests that might hinder its proper functioning.

The weak appropriation of technical tools

Once it was set up, how was the laboratory appropriated by Chadian actors? To explain this phenomenon, we can resort to the notion of ‘diversion’ developed by Mathieu Quet (2018) in the case of hepatitis treatments, after Claire Beaudevin and Laurent Pordié (2016). In the Chadian context, the technical tools for drug quality control are somehow diverted by the laboratory technicians, the private actors, and the state. However, to push this notion further, I insist on the variety of practices through which diversion is manifested. In the following sections, I analyse the inner workings of the laboratory and show the difficulties in appropriating the technical equipment for controlling the quality of medicine to global standards, the hardship in convincing the distributors to get their product tested in the lab, and the repurposing of technical facilities for hydroalcoholic gels in times of COVID-19.

Installing technological equipment to control the quality of pharmaceutical products is part of a series of reforms carried out over the years to combat falsified products. It requires the use of several instruments pictured in Figure 8.2. For instance, HPLC (high-performance/pressure liquid chromatography) columns are used for the analytical and preparative separation of molecules in a mixture. The lab also hosts ultra-performance liquid chromatography (UPLC) instruments, which offer a slightly different level of analysis with good chromatographic resolution, and an ultraviolet-visible spectrometer (UVS) for breaking down a quantity observed in a light beam – for spectroscopy – or in a mixture of molecules. The laboratory is also equipped with disintegrators, analytical scales, and dissolution testers, enabling quality control of a drug through the substances used by the pharmaceutical industry. In this physicochemical laboratory, two types of control are carried out using these devices. The first is a physical drug analysis, which checks the packaging, expiration date, country of origin, package inserts, and other physical elements. The second check is an in-depth chemical analysis of the drugs. This quantitative and qualitative analysis checks the presence and composition of active ingredients.

All these devices should enable the laboratory’s technicians to carry out quality control of medicines destined for the Chadian pharmaceutical market. According to the laboratory’s quality manager, ‘in principle, with such [devices], we can reduce our dependence and make consumers trustful’. The dependency highlighted by my interlocutor in this interview is linked to the use of drug quality control laboratories located abroad. Indeed, before the advent of the Chadian laboratory in 2019, importers of industrial medicines into the Chadian pharmaceutical market were required to have a sample of the drugs tested in countries such as Niger, Kenya, or France before receiving clearance from regulatory authorities, which allows for the distribution of the medicines in Chad. The difficulties in implementing projects to secure medicines in the Chadian pharmaceutical market are reflected by the various processes of appropriation by local actors.

The concept of appropriation is used in various fields. However, it generally refers to the process whereby a person or group assumes control of something, be it an object, an idea, a culture, or even a space, for its own purposes. This usually involves claiming ownership, control, or use of a good or an aspect of a culture and can have positive or negative consequences, depending on the context and how it unfolds on the ground. The sociology of use and innovation is helpful here. It has documented appropriation practices for years, implementing instrumental approaches through the internalisation or externalisation of technical objects (De Vaujany 2006; Morigi and Braga 2014). My own investigation leads to the observation that the appropriation of this technical facility by the local pharmaceutical players was first and foremost very limited, as testified by the manager of Laborex Chad.

Today, in the Chadian pharmaceutical market, the Centrale Pharmaceutique d’Achat is the only wholesaler to have its drugs checked by the national medicines quality control laboratory that’s been created.

Since it was set up in 2019, the Centrale Pharmaceutique d’Achats (CPA), as a public wholesale procurement agency, has had its medicines controlled by the laboratory. To date, it is the only Chadian wholesaler involved in distributing industrial pharmaceuticals on the market to have had its imported industrial pharmaceuticals inspected – out of over 38. The CPA’s use of the quality control laboratory is explained by the nature of the institution – financed by the World Bank – and by its mission to ensure the supply of medicines for the public sector. At the turn of the 1990s, the World Bank financed the establishment of drug import institutions in Africa, for example in Benin, where the Central Purchasing Center for Essential Medicines and Medical Consumables (CAME) began operations in 1991 (Mahamé and Baxerres 2015). This period highlights the World Bank’s paradigm shift to focus on poverty reduction in developing countries and on building infrastructure. In keeping with the promises made by the Chadian government to international organisations, the CPA presents a semblance of normativity in relation to the purposes announced during the laboratory’s inauguration in 2019. Thus, official discourse and the laboratory’s actual use are in contradiction, highlighting the tension between global objectives and local needs and practices.

The circumvention of quality control

If the CPA imports solely generic drugs, the wholesale distributors import branded or specialised drugs. For several of these players, the analysis of brand-name drugs may require a level of experience not available to the technicians of the Chadian laboratory. The apparent struggle of the Chadian technicians in appropriating some technical tools was often used as a reason for circumventing the drug control process at the laboratory established in N’Djamena. As with appropriation, the circumvention principle captures another strategy players resort to in the Chadian market. It involves the non-take-up of technical facilities provided by the World Bank, such as the medicines quality control laboratory. The Chadian pharmaceutical market includes 38 private wholesale distributors (alongside the publicly funded CPA) that take part in the distribution of medicines but try to bypass the laboratory for the quality control of imported pharmaceutical products. They have never resorted to the services offered by this laboratory, in spite of the stipulation in Chadian pharmaceutical regulations that quality control of imported medicines is mandatory, whether by the national system or approved foreign services:

Pharmaceutical products imported for the Chadian market have to pass through Niger, Kenya, or France for certification before being distributed on the local market. This means that the products have to be quarantined, and as soon as the wholesaler shows us the certification of its merchandise, the authorities can lift the quarantine on these products, but unfortunately, the opposite is happening. (Interview with the director of pharmacy and laboratory, N’Djamena, 2021)

This excerpt from an interview with the director of pharmacy shows that wholesalers circumvent the system by distributing medicines without first having them tested by the quality control laboratory. How can such circumvention be explained when the system was created precisely for these players? There are several reasons. First, analysing samples in this laboratory means quarantining the products during the analysis period, whereas wholesale distributors look for quick profit from imports. One, based in N’Djamena, explained: ‘Despite all the talk of quality control in this new laboratory, the waiting time can be a bit long, so we prefer to bypass the system and not quarantine the medicines’. While time is one of the factors put forward as a reason for circumventing the laboratory, the atypical profile of wholesale distributors also plays a vital role in this choice. A large proportion of them are not pharmacists but traders, and the few pharmacists involved in importation are associates or nominees, as explained by the head of Laborex Chad:

More than half of Chad’s wholesalers are not pharmacists. The country does not have enough pharmacists, and the few who do work in the Chadian market don’t have the necessary means to run a wholesale business in the current context. (Interview with head of Laborex Chad, N’Djamena, 2021)

In addition to the lack of laboratory technicians’ experience, the importers’ profiles also play a significant role in circumvention. Among the 38 wholesale distributors, fewer than 10% are pharmacists associated with the companies importing industrial medicines. This low percentage of pharmacists in the importing companies may facilitate circumvention. At this level, circumvention refers to the refusal to quarantine imports before distribution in the Chadian pharmaceutical market. Additionally, the failure of wholesalers to comply with quarantine requirements has been facilitated by the corruption that has plagued the sector for several years. The close relations between certain Chadian customs officials and wholesale distributors facilitate this corruption and non-compliance with drug quarantine, which benefits private players. Customs is, moreover, not the only factor explaining corruption within the pharmaceutical system; community ties also play an essential role in circumventing technical facilities.

It is true that some customs officials are very helpful, but not everyone. Several senior customs officials are part of the Zaghawa community, and so are wholesale distributors, so it’s really easy to reach an agreement to avoid this quarantine. (Interview with a wholesale distributor based in N’Djamena, 2021)

This reveals another factor facilitating laboratory circumvention by certain actors in the Chadian pharmaceutical market. It indeed gives a communal dimension to the circumvention. Certain members of the Zaghawa community, which he mentions, have been controlling the security apparatus (police, intelligence agency, national army, customs) for over three decades. Many of the medicine importers belong to this community, which is close to the centres of state power in Chad. These medicine importers use their relationship with members of the security apparatus close to the current regime in Chad to circumvent the directives of the regulatory authority related to the control of industrial medicines at the national laboratory. Circumvention set up by groups close to power in Chad can be analysed in the context of accumulation and power relations, as Achille Mbembe recalls in his work on power, violence, and accumulation (Mbembe 1990). The exercise of power, following Mbembe’s concept, allows certain groups or individuals to gain control over resources and a free pass in various activities they undertake (Mbembe 2004, 2010). The concern for accumulation by these actors close to power allows for the observation of a form of confusion between the public and private sectors, as described in the works of Jean-François Médard (1976). In the light of these approaches developed in the work of Médard and Mbembe, if bypassing is a form of accumulation and influence, another phenomenon has its roots in the colonial context, or at least a colonial complex.

Indeed, circumvention can also be explained by postcolonial factors. In her research on the Beninese pharmaceutical market, Carine Baxerres (2011) demonstrates how francophone African countries, at the end of decolonisation, chose to import industrial medicines from France and buried, or at least did not encourage, the project of building a pharmaceutical industry like that of some anglophone countries in Africa. This also translates in the Chadian case. According to several Ministry of Health officials, medicines imported by wholesalers based in France are usually considered safe, good-quality products and are therefore not checked. This view has long been held in the French-speaking countries of Sub-Saharan Africa, but it is essential to question the trust invested in drugs imported from France. These countries often lack the human and technical resources to monitor imported medicines. Connecting drug quality to the supplier country thus becomes a justification in the discourse of local actors, even if history teaches us that the country of importation is not synonymous with the quality of an industrial pharmaceutical product. ‘For a long time, the system endorsed this practice of equating quality with France, which may partly explain this circumvention’ (interview with a former pharmaceutical inspector, N’Djamena, 2021). The discourse of substitution promoted by local actors represents a form of Chad’s dependency on its former colonial ruler. The supply chain established by the French colonial empire thrived even after Chad’s independence in 1960. According to this model, supply was exclusively conducted with French pharmaceutical industries. However, since the rise of China and India as producers of industrial medicines, the circuit has significantly diversified. As we can see, multiple reasons explain the circumventing of the laboratory facility by Chadian actors. However, circumvention is not the only form of diversion or loose appropriation of the apparatus.

The repurposing of technical facilities

With the COVID-19 pandemic, as borders are closed, the national medicines quality control laboratory has enabled Chad to produce hydroalcoholic gels for the public and hospital supply, thanks to the contribution of the SWEDD project. (Remarks by the World Bank representative in Chad during the presentation of the first batch of hydroalcoholic gel manufactured by the laboratory financed by his institution to deal with the pandemic, N’Djamena, April 2020)

The above statement reveals another use of the technical tools initially intended for the quality control of industrial medicines in Chad. This statement also highlights the adaptability of local actors. The COVID-19 pandemic thus led to an alternative use of Chad’s very first national medicines quality control laboratory. Since its establishment in 2019, the laboratory has never reached its maximum level of drug control in Chad. It is still in its infancy, and in terms of staffing (nine people), it cannot achieve the initial goal. The laboratory technicians were recruited via the SWEDD project and could only train once the technical tools had been installed on the laboratory premises. They include chemists, biologists, and public health specialists, among others. This diversity of profiles, coupled with the absence of skills to perform chemical analysis of drugs, allowed the laboratory’s initial purpose to be diverted during the pandemic.

During the pandemic, my friends and I decided to use the technical tools in the laboratory to manufacture hydroalcoholic gels for hospitals, dispensaries, and clinics – in short, for all Chadians. Thanks to the support of the Chadian government, we could manufacture over 50,000 units of hydroalcoholic gel. (Interview with head of laboratory quality control, N’Djamena, 2021)

The interview revealed the repurposing of the facility intended for drug quality control for the manufacture of hydroalcoholic gels. Given the technicians’ profile, outlined above, the Ministry of Health provided additional resources for purchasing chemicals to manufacture hydroalcoholic gels. In so doing, it sought not only to demonstrate the operationality of the laboratory with a product ‘made in Chad’ but also to meet the needs of the population faced with a shortage of hydroalcoholic gels during the closed-border period. Against the backdrop of a global health crisis and multiple shortages, this repurposing also reflected the readaptation of a technical facility to the Chadian environment. It demonstrated the ability of local players to appropriate and modify the use of a facility designed to control industrial pharmaceuticals only. Through the national medicines quality control laboratory set up in Chad, we thus observe a bottom-up reconfiguration and readaptation of a system imposed from above. Empirical data also show the need to distinguish between a promise made by the authorities when they agreed to implement the technical facilities and the actual use of those facilities. As the wholesale distributor based in N’Djamena commented: ‘It’s more a matter of keeping up appearances for its financial and technical partners than of controlling medicines’. But wasn’t it urgent for Chadian people to use hydroalcoholic gel?

Conclusion

The galloping demography of the Chadian population2 is resulting in a growing need for medicines, which will increase the already substantial flow of pharmaceutical products and the role of transnational players in controlling supply circuits. International organisations, including primarily the World Health Organisation and the World Bank, have historically played a central role in the securitisation of medicines in the Global South. They have been investing in the (re)construction of the Chadian pharmaceutical market, exerting their influence on it through the reshaping of traditional control institutions: a pharmaceuticals inspectorate, a health police, and a regulatory authority. All these institutions have now been permeated by international organisations, through staff training, provision of material resources, or the diffusion of normative principles promoting the securitisation of Chadian pharmaceutical markets. Yet the means provided to ensure the proper functioning remain insufficient. The presence of international organisations in the Chadian pharmaceuticals market therefore appears primarily as a manifestation of the new reconfiguration of global health policies, one pillar of which is the pharmaceutical system and its securitisation.

However, this case study also shows that the Chadian government can navigate through the interests manifested by international actors and external funders. In this regard, the implementation of the lab is significant of the appropriation, circumvention, and diversion that happen in the Global South regarding international standards and funds. The Chadian case illustrates, first, how resource-poor states oscillate between signs of good will and practices of diversion; it also shows how the repurposing of the technical equipment meant to control and secure the flow of industrial pharmaceuticals brings Chad into the global medicine economy in a singular way. Retracing the genesis of the technical facility for controlling the quality of medicines and its uses shows that the technical facility has been reappropriated, repurposed, or even circumvented due to the various power dynamics between the actors involved. Adopting such a control apparatus has been far from a top-down process and has resulted in the creation of a lab whose functioning is very distinct from international standards and largely embedded in the Chadian context.

Technoscientific globalisation thus appears not only as a matter of top-down, global-local, and unidirectional exchange, but as a back-and-forth process and a series of adjustments. Despite the significant influence of international actors in disseminating standards and technical tools in the Global South, the Chadian case demonstrates that local actors do not align entirely and have a margin of action. Whether these global processes are just slowed down or entirely reinvented by local populations, however, is to be interrogated. Observing the evolution of technical devices for the quality control of medicines in Chad suggests that the country, rather than ‘integrating’ the global pharmaceutical markets through the one-way adoption of standardised devices and modes of control, will keep on developing its own model of drug monitoring and its own pharmaceutical rules. To take this into account, further research will have to pay increased attention to the agency of Global South players rather than documenting only the ways in which they are dominated by the most powerful actors on international markets.

Endnotes‌

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