Normalizing Off-Label Experiments and the Pharmaceuticalization of Homebirths in Pakistan

Abstract

The off-label use of the drug misoprostol has effectively turned homebirths in ‘resource-poor’ nations into unmarked and un-enunciated zones of experimentation. Misoprostol has become the public health solution in response to medico-humanitarian discourses that construct homebirths as responsible for high maternal mortality. In the absence of proper safety tests, advocating its routine administration against postpartum haemorrhage in homes around Pakistan functions to erase the distinction between service delivery projects and experimentation. Drawing on ethnographic research in Balochistan, I argue that promoting misoprostol in contexts of structural inequality, particularly where excessive artificial labour induction prevails, constitutes the enactment of a kind of ‘medical relativism’. This medical relativism entails an experimental practice that burdens poor women with undue risk as misoprostol becomes a substitute for required structural and economic transformation of Pakistan's healthcare system. Overall, the paper concludes, the contemporary faith in pharmaceuticals perpetuates a colonial governmentality of bodies, medicines, and healthcare.

Keywords:

• Colonial governmentality
• medical relativism
• experimental
• reproductive technologies
• misoprostol
• maternal mortality

Acknowledgments

I am grateful to all the women, men, and families in Panjgur and elsewhere in Balochistan and Pakistan for their time, generosity, and patience towards my research. I thank Lawrence Cohen and Shalini Randeria for their critical insights. Many others provided thoughtful comments on more recent and earlier versions including, Kalindi Vora, Juliet McMullin, Nancy Chen, Carlo Caduff, Adele Clarke, Sharon Kaufman, Paola Bacchetta, and Vincanne Adams. This paper has also benefited from discussion with Hasineh and Malek Towghi, Anju Gurnani and draws from my doctoral research supported by University of California, San Francisco and Berkeley, the Woodrow Wilson and Johnson and Johnson Women's Health Fellowship, the American Association of University Women, and the American Institute for Pakistan Studies.

Notes

1. All indentifying information about people and institutions has been changed.

2. For a linguistic meanings and detailed understanding of kawwās, dïnabog, or balloks, see Towghi (2012).

3. Gidam is a housing structure, made of black goat hair and frond of date palm leaves, still common in Southern Balochistan and in the Sarhard plateau of Southeastern Iran.

4. Elsewhere (Towghi 2012) I address the direct and problematic links between increased uses of artificial labour induction with prostaglandins and the dramatic rise in hysterectomies experienced by Panjguri women.

5. The use of an approved product for a purpose that is not included in its labeling is common and in accord with FDA (1982) guidelines if there is published evidence to support such use. See Joffe and Wietz (2003) for debates regarding off-label uses of the imfepristone or RU-486 in the USA.

6. SAPs were first introduced in Latin America in the late 1970s, then in Africa in the 1980s followed by their introduction in Asia in the 1990s. Such policies required the elimination of public sector services, utilities, and health care, lifting price controls, freezing or lowering wages, devaluing local currencies, and reducing subsidies on basic essentials, which made it more difficult for ordinary people to obtain food, transport, education, and health care (Nair et al. 2006).

7. http://www2.ohchr.org/english/bodies/hrcouncil/. See also the International Initiative on Maternal Mortality and Human Rights (http://righttomaternalhealth.org/).

8. Waldy and Cooper (2008) employ the term ‘bio-economy’ to refer to the biomedical economy as a whole including transnational commerce associated with medical drugs, medical devices, body parts (organs and tissue including blood), and medical/clinical research.

9. For examples, see the works of Mass (1976), Hartman (1987), Bandarage (1997), and Connelly (2008).

10. See Ferguson (1994), Escobar (1995), and Gupta (2000 [1998]) for such examples in the agriculture sectors in Africa and India and their critiques of development.

11. For the WHO position, see http://www.who.int/making_pregnancy_safer

12. In Pakistan 80% of childbirth deliveries (90% in Balochistan) occur at home (Government of Pakistan 2000).

13. See Pigg (1997) and Towghi (2004) for a critique of the reductive representation of TBAs in development practice.

14. See also http://www.clinicaltrials.gov NCT00116480 for two clinical trials on misoprostol in Pakistan conducted in collaboration with Gyunity Health Projects and the Aga Khan University.

15. See Tansey (2001) for the nineteenth and twentieth century uses of Ergot in childbirth.

16. See USFDA: http://www.fda.gov/medwatch; htttp://www.drugs.com/pro/pitocin.html

17. The WHO, however, currently includes misoprostol in its evidence-based guidelines and Model List of Essential Medicines for early pregnancy termination together with mifepristone, medical management of miscarriage, and labour induction.

18. The re-figuration of the TBA capable of administering the misoprostol pill resembles the brief period she was instrumentalized in the past to distribute contraceptives because of her favourable links with communities and her accessibility to women's homes (Bandarage 1997).

19. For a developed discussion of ‘triage’, see Nguyen (2010).

20. See Koenig (1988) for a critical discussion of the social creation of routine practice in biomedicine.

21. This type of experimental introduction is evident also in current HPV vaccine research and trials in India (Towghi 2013).

22. See Committee on Women, Population, and the Environment (http://cwpe.org).