‘Pharmatrash’ in South Africa: A Contemporary History of Democracy’s Detritus

ABSTRACT

This study examines what happens to pharmaceutical products after they have been provided, purchased, consumed and discarded. Based on an archive of medical materials, constituted over three years of collecting waste in public sites around South Africa’s Eastern Cape, I analyse the uses of these products in relation to two key developments in post-apartheid history: new forms of healthcare provision and consumption; and the diversity of formal, adaptive and illicit uses of pharmaceuticals. I highlight the example of the opioid analgesic – codeine – among the most accessible and widely abused pain-killers in South Africa’s pharmaceutical compendium. Through comparing local instances of codeine abuse, I draw historical connections between current and past uses of proprietary (‘over-the-counter’) medicines. The ‘pharmatrash’ in this study is the product of global developments: modern scientific research, its technological and commercial applications, and the expansion of the pharmaceutical market in the twentieth century. These materials are also resonant of national developments: the democratisation of healthcare, the burden of communicable and non-communicable diseases, and patterns of material acquisition and consumption. This article explores the social and political meanings of this ‘detritus of democracy’ in contemporary South Africa.

KEYWORDS:

• Pharmaceutical waste
• discard studies
• healthcare
• sanitation
• democracy
• post-apartheid South Africa
• commodity consumption
• codeine
• Eastern Cape
• Buffalo City

Acknowledgments

The research has benefitted from the comments of participants within three academic fora: a workshop on ‘Drug Regimes in Southern Africa: Regulation and Consumption in Twentieth Century Contexts’, held at the University of Johannesburg (November 2017); a seminar held at the University of Cape Town’s Centre for Social Science Research (October 2018); and a presentation at the ‘States of Dis-Ease’ Conference, hosted by the Johannesburg Institute for Advanced Research (March 2019). For their generous support and scrupulous revisions, I am grateful to Julie Parle and Thembisa Waetjen. For their guidance on conceptual and analytical approaches, I am indebted to Deborah Posel, Lesley Green, Nicole Daniels, Stacy Hardy, William Beinart and Beth Vale. For his insights into pharmaceutical provisions in South Africa, I thank Andy Gray. This research was conducted alongside a large, longitudinal study on medicines-taking in the Eastern Cape, the Mzantsi Wakho study. I am grateful to study collaborators and, in particular, co-Principal Investigators, Lucie Cluver and Elona Toska.

Note on the contributor

Rebecca Hodes is a medical historian. She is the Director of the AIDS and Society Research Unit at the University of Cape Town, and an Honourary Affiliate of the Department of Social Policy and Investigation at Oxford University. Hodes is the co-Principal Investigator of the Mzantsi Wakho study, about antiretroviral adherence and sexual health among teenagers living in the Eastern Cape.

ORCID

Rebecca Hodes http://orcid.org/0000-0002-2502-803X

Notes

1 S. Mlambo, ‘Medical Waste on Beaches: Durban Vows Action’, IOL, 19 May 2016, https://www.iol.co.za/news/medical-waste-on-beaches-durban-vows-action-2023822, accessed 24 January 2019.

2 S. Kingon, ‘Dump Sites Crisis’, Express Community Centre: Buffalo City and Cintsa, 15 May 2016, https://showme.co.za/east-london/news/dump-sites-crisis/, accessed 14 August 2019; S. Kretzman, ‘Nasty Chemicals Are Accumulating on Cape Town’s Coasts’, GroundUp, 12 February 2019, https://www.groundup.org.za/article/nasty-chemicals-are-accumulating-cape-towns-coasts/, accessed 14 August 2019; N. Damba-Hendrik, ‘Garbage Piles Up In Cambridge, East London’, GroundUp, 8 March 2019, https://www.groundup.org.za/article/garbage-piles-cambridge-east-london/, accessed 14 August 2019; R. Southall, ‘Littering In South Africa Is The Expression Of Wider Selfish – And Costly – Culture’, The Conversation, 9 May 2018, https://theconversation.com/littering-in-south-africa-is-the-expression-of-wider-selfish-and-costly-culture-96186, accessed 14 August 2019.

3 See S. Robins, ‘Poo Wars As Matter Out Of Place: “Toilets For Africa” In Cape Town’, Anthropology Today, 30 (2014), 1–3; and C. McFarlane and J. Silver, ‘The Poolitical City: “Seeing Sanitation” and Making the Urban Political in Cape Town’, Antipode, 49, 1 (2017), 125–148 for discussions of the uses of biological waste as media for civic action. The use of human waste as a medium of protest within the #Fees Must Fall movement has inspired extensive news coverage and scrutiny. See, for instance, R. Hodes, ‘Questioning Fees Must Fall’, African Affairs, 116, 462 (2017), 142–143; Groundup Staff, ‘Protestors Throw Poo Into UCT’s Law And Economics Buildings’, GroundUp, 17 October 2016, https://www.groundup.org.za/article/protesters-throw-poo-ucts-law-building/, accessed 12 January 2019; and S. Ralana, ‘Protest In UCT Residences’, Varsity, 10 April 2018, http://varsitynewspaper.co.za/2018/04/10/protest-in-uct-residences/, accessed 12 January 2019.

4 This study was conducted within the parameters of a wider research project, the Mzantsi Wakho study, about the health practices of adolescents (aged 10–19) and adult caregivers, as well as healthcare workers and social service providers. Ethical approval for this study was provided by Research Ethics Committees at the Universities of Oxford (SSD/CUREC2/12-21) and Cape Town (CSSR 2013/4), the Eastern Cape Departments of Health and Basic Education, and the ethical review boards of participating hospitals. Following a deliberative approach to ethical permissions, this study seeks ongoing guidance to ensure consent and protect confidentiality during primary research, analysis and dissemination. For further information about study methods and findings, see, for instance, R. Hodes, B. Vale, E. Toska, L. Cluver, R. Dowse and M. Ashorn, ‘“Yummy or Crummy?” The Multisensory Components of Medicines-Taking Among HIV-Positive Youth’, Global Public Health, 2018, 1–17; R. Hodes and L. Gittings, ‘Kasi Curriculum: What Young Men Learn and Teach about Sex in a South African Township’, Sex Education, 19, 4 (2019), 436–454.

5 J. Pickstone, ‘Production, Community and Consumption: The Political Economy of Twentieth-Century Medicine’, in R. Cooter and J. Pickstone, eds, Companion to Medicine in the Twentieth Century (London: Routledge, 2003), 17.

6 B. Goldacre, Bad Pharma: How Drug Companies Mislead Doctors and Harm Patients (London: Fourth Estate, 2012), 240–340. The current ‘opioid crisis’ in the United States, for instance, highlights the perils of incautious drugs promotion and prescription, in particular of habit-forming substances.

7 A. McLellan and B. Munslow, ‘Introduction’, in A. McLennan and B. Munslow, eds, The Politics of Service Delivery (Johannesburg: Wits University Press, 2001), 3.

8 Republic of South Africa, Government Gazette, Notice No. 1954 of 1994, Parliament of the Republic of South Africa, White Paper on Reconstruction and Development, Cape Town, 15 November 1994, https://www.gov.za/sites/default/files/governmentgazetteid16085.pdf, accessed 30 July 2019. The Reconstruction and Development Programme: A Policy Framework (authors unstated) can be found at https://www.sahistory.org.za/sites/default/files/the_reconstruction_and_development_programm_1994.pdf, accessed 30 July 2019.

9 Sections 2.6, ‘Water and Sanitation’, The Reconstruction And Development Programme: A Policy Framework, https://www.sahistory.org.za/sites/default/files/the_reconstruction_and_development_programm_1994.pdf, accessed 30 July 2019.

10 Ibid.

11 D. Everatt, ‘The Undeserving Poor: Poverty and the Politics of Service Delivery in the Poorest Nodes of South Africa', Politikon, 35, 3 (2008), 293–319.

12 Chief Legal Officer, ‘Dealing Ethically with Medical Waste’, Continuing Professional Development (CDP), 1.

13 K. du Toit and J. Bodenstein, ‘Disposal of Medical Waste: A Legal Perspective’, South African Medical Journal, 104, 1 (2014), 14.

14 However, public stock-outs of medical technologies are documented frequently. These expose dysfunctionality within the public health sector, highlighting a lack of pharmacovigilance mechanisms, and faulty medicines procurement and supply-chain management. See, for instance, R. Hodes, I. Price, N. Bungane, E. Toska and L. Cluver, ‘How Frontline Healthcare Workers Respond to Stock-Outs of Essential Medicines in the Eastern Cape’, South African Medical Journal, 107, 9 (2017), 738–740.

15 R.R. Makhura, S.F. Matlala and M.P. Kekana, ‘Medical Waste Disposal at a Hospital in Mpumalanga Province, South Africa: Implications for Training of Healthcare Professionals’, South African Medical Journal, 106, 11 (2016), 1096–1102; M. Nkwana, ‘The Security Risk Associated With Illegal Dumping of Medical Waste on Dump Sites in South Africa’, Servamus Community-Based Safety and Security Magazine, 110, 9 (2017), 34–35; C. van Schalkwyk, ‘A Challenging Context’, ReSource, 15, 2 (2013), 41–43; A. Retief, ‘Dumping Medical Waste’, Emergency Services SA/Occupational Risk, 1, 14 (2010), 21–22; D. Govender and A. Ross, ‘Sharps Disposal Practices among Diabetic Patients Using Insulin’, South African Medical Journal, 102, 3 (2012), 163–164.

16 D. Posel and I. van Wyk, ‘Thinking with Veblen: Case Studies from Africa’s Past and Present’, in D. Posel and I. van Wyk, eds, Conspicuous Consumption in Africa (Johannesburg: Wits University Press, 2019), 1–3.

17 R. Hodes, ‘Popular Perspectives on Teenage Pregnancy in South Africa’, in N. Mkhwanazi and D. Bhana, eds, Young Families: Gender, Sexuality and Care (Cape Town: Human Sciences Research Council Press, 2017), 17–30; R. Hodes, E. Toska and L. Gittings, ‘Babies for Bling: Are Teenage Girls Having Children to Access Grants?’, HIV Nursing Matters, 7, 2 (2016), 20–23; I. van Wyk, ‘Jacob Zuma’s Shamelessness: Conspicuous Consumption, Politics and Religion’, in Posel and Van Wyk, Conspicuous Consumption, 112–125.

18 Nkwana, ‘Illegal Dumping’, 34; See citations in footnote 2 for further sources. For a focus on illegal dumping in Buffalo City in specific, see N. Damba-Hendrik, ‘Garbage Piles Up in Cambridge, East London’, Groundup, 8 March 2019, https://www.groundup.org.za/article/garbage-piles-cambridge-east-london/, accessed 14 August 2019; and S. Kingon, ‘Dump Sites Crisis’, Express Community Centre: Buffalo City and Cintsa, 15 May 2016, https://showme.co.za/east-london/news/dump-sites-crisis/, accessed 14 August 2019.

19 M.R. DiMatteo, ‘Variations in Patients’ Adherence to Medical Recommendations: A Quantitative Review of Fifty Years of Research’, Med Care, 42, 3 (2003), 200; P. Rudd, ‘In Search of a Gold Standard for Compliance Measurement’, Archives of Internal Medicine, 139, 6 (1979), 627–628.

20 J. Stadler, F. Scorgie, A. van der Straten and E. Saethrie, ‘Adherence and the Lie in a HIV Prevention Clinical Trial’, Medical Anthropology, 35, 6 (2016), 503–516; R. Hodes, L. Cluver, E. Toska and B. Vale, ‘Pesky Metrics: The Challenges of Measuring Antiretroviral Treatment Adherence among HIV-Positive Adolescents in South Africa’, Critical Public Health, 28, 4 (2018), 1–12; B. Vale and M. Thabeng, ‘Mobilising AID(S)? Contesting HIV as a Social and Economic Resource among Youth in South Africa’s Eastern Cape’, Journal of Southern African Studies, 41, 4 (2015), 1–17; B. Vale, R. Hodes, L. Cluver and M. Thabeng, ‘Bureaucracies of Blood and Belonging: What Documents Tell Us About the Relationship between HIV-Positive Youth and the South African State’ Development And Change, 48, 6 (2017), 1287–1309.

21 M. Acuto, ‘Everyday International Relations: Garbage, Grand Designs, and Mundane Matters’, International Political Sociology, 8 (2014), 345.

22 C. Smith, ‘Accumulating History: Dirt, Remains and Urban Decay in Nairobi’, Social Dynamics, 44, 1 (2018), 121–122; D. Offenhuber, Waste is Information: Infrastructure Legibility and Governance (Cambridge: MIT Press, 2017), 1; A. Jerardino, ‘Large Shell Middens in Lamberts Bay, South Africa: A Case of Hunter-Gatherer Resource Intensification’, Journal of Archaeological Science, 37, 9 (2010), 2291–2302.

23 D. Offenhuber, Waste is Information: Infrastructure Legibility and Governance (Cambridge: MIT Press, 2017), 3; R. Hering, ‘The Need for More Accurate Data in Refuse Disposal Work’, American Journal of Public Health, 2, 12 (1912), 909–911; R. Hering and S. Greeley, Collection and Disposal of Municipal Refuse (New York: McGraw-Hill, 1921).

24 A.L. Stoler, ‘Imperial Debris: Reflections on Ruins and Ruination’, Cultural Anthropology, 23, 2 (2008), 191–219.

25 W. Rathje and C. Murphy, Rubbish! The Archaeology of Garbage (Tucson: University of Arizona Press, 2001).

26 M. Liboiron, ‘Redefining Pollution and Action: The Matter of Plastics’, Journal of Material Culture 21, 1 (2016), 87–110.

27 S. Newell and L. Green, ‘Putting Dirt in its Place: The Cultural Politics of Dirt in Africa’, Social Dynamics, 44, 2 (2018), 1–5; S. Newell and L. Green, ‘Dirt Redeployed: The Cultural Politics of Dirt Continued’, Social Dynamics, 44, 1 (2018), 179–183.

28 A.M. Brandt and M. Gardner, ‘The Golden Age of Medicine?’, in Cooter and Pickstone, Companion to Medicine, 22.

29 M. Douglas, Purity and Danger: An Analysis of Concepts of Purity and Taboo (London: Routledge & Kegan Paul, 1966), 35–36.

30 My thanks to Andy Gray for this information.

31 Further information about IQVIA is available at https://www.iqvia.com/about-us, accessed 12 August 2019.

32 R. Cyran, ‘Deciphering the Quintiles-IMS Merger’, The New York Times, 3 May 2016, https://www.nytimes.com/2016/05/04/business/dealbook/deciphering-the-quintiles-ims-merger.html, accessed 12 August 2019.

33 T. Holt, M. Lahrichi, J. Mina, and J. Santos da Silva, ‘Insights into Pharmaceuticals and Medical Products Africa: A Continent of Opportunity for Pharma and Patients’, McKinsey&Company (April 2015), 4–6, https://www.mckinsey.com/~/media/mckinsey/industries/pharmaceuticals%20and%20medical%20products/our%20insights/africa%20a%20continent%20of%20opportunity%20for%20pharma%20and%20patients/pmp%20africa%20a%20continent%20of%20opportunity%20for%20pharma.ashx, accessed 12 August 2019.

34 Due, in part, to this backlog in the MCC’s approval or rejection of new medicines and therapeutics, an adjacent body, SAHPRA was established to expedite this work. Numerous challenges remain relating to pharmacovigilance and the oversight and registration of pharmaceuticals in present day South Africa. See, for example, the South African Medical Research Council, ‘Annual Report 2017/2018’ (2018), 101, http://pmg-assets.s3-website-eu-west-1.amazonaws.com/1/SAMRC_Annual_Report_20172018_2.pdf, accessed 10 September 2019.

35 Interview with pharmacist and owner of multiple pharmacies, 8 August 2018, East London. For a polemical critique of unscrupulous retailers and their promotion of pseudo-scientific pharmaceutical products, see A. McAlpine, ‘SA’s Pharmacies Are Gollums, Not Trusted Gate-Keepers’, Medical Brief, 11 July 2018, https://www.medicalbrief.co.za/archives/sas-private-pharmacies-golllums-not-trusted-gatekeepers/, accessed 12 August 2019.

36 A number of complaints against the manufacturers of dietary supplements for false advertising have been laid with the Advertising Authority of South Africa. See H. Steinman and N. Geffen, ‘South Africa: Complementary Medicine Companies are Destroying Consumer Protection’, GroundUp, 30 May 2016, https://www.groundup.org.za/article/complementary-medicine-companies-are-destroying-consumer-protection/, accessed 12 August 2019.

37 The South African Constitution (Act 108 of 1996) stipulates that every person has the right to an environment that is not harmful to their health and well-being, including through the protection and preservation of the environment.

38 H. Coovadia, R. Jewkes, P. Barron, D. Sanders and D. McIntyre, ‘The Health and Health System of South Africa: Historical Roots of Current Public Health Challenges’, The Lancet, 374 (2009), 828.

39 L. Bank, Home Spaces, Street Styles: Contesting Power and Identity in a South African City (Johannesburg: Wits University Press, 2001); C. Olver, How To Steal A City: The Battle for Nelson Mandela Bay, An Inside Account (Johannesburg: Jonathan Ball, 2017).

40 For a discussion on new directions and contestations in South African historiography, see A. Grundlingh, C. Saunders, S. Swart and H. Phillips, ‘Environment, Heritage, Resistance and Health Newer Historiographical Directions’ in R. Ross, A.K. Mager and B. Nasson, eds, The Cambridge History of South Africa: Volume II, 1885–1994 (Cambridge: Cambridge University Press, 2012), 608–609.

41 B. Freund, Twentieth-Century South Africa: A Developmental History (Cambridge: Cambridge University Press, 2019); W. Gumede, ‘Delivering the Democratic Developmental State in South Africa’, in McLennan and Munslow, The Politics of Service Delivery, 43–103.

42 C. Hamilton, ‘The Long Southern African Past: Enfolded Time and the Challenges of Archive’, Social Dynamics, 43, 3 (2017), 350.

43 J. Reno, ‘Waste and Waste Management’, Annual Review of Anthropology, 44 (2015), 558.

44 While not classifiable as pharmaceuticals as such, it was notable that discarded cans of energy drink, such as Play and Score, which contain high doses of sugar and caffeine, were often found within dump sites and along kerbsides, another quick and accessible means of boosting energy and maintaining wakefulness. The heavy consumer demand for these drinks was evident in their sale within study sites, by hawkers, at busy traffic intersections, including outside Frere Hospital in East London (the largest public hospital in the Buffalo City Metropole).

45 This archive includes 10 of these products: Autrin, AntaGolin, Balsol, Berocca, Bioplus, Cardio-Health, Pharmaton, Reuterina, SuperCharge and Vita-Thion. Other common items of pharmatrash in this research also include a variety of immune boosters, antioxidants and vitamins. Linctagon-C, touted as a hay fever, cold and flu remedy, includes extracts of Pelargonium sidoides (commonly known as African geranium) which, according to its advertising, ‘supports the immune system and helps relieve the symptoms of colds and flu’. Linctagon-C also includes vitamins A, C and Zinc, ‘for further immune and antioxidant support’. Product information is available at https://clicks.co.za/linctagon-c_infection-and-hayfever-support-orange-12-effervescent-tablets/p/102067, accessed 11 August 2019. A tablet of Corenza, a popular cough, cold and flu medicine, is constituted by 650 mg of paracetamol, 10 mg of phenylephrine HCI, and 250 mg of Vitamin C. Corenza’s enduring popularity among South African consumers is demonstrated, in part, through its availability for online purchase and worldwide shipping via the expatshop.co.za, accessed 11 August 2019. A South African ex-patriot living in Britain, for example, could order a box of Corenza (containing 10 tablets), and be guaranteed its arrival at a British residence within 14 days of purchase.

46 Statistics South Africa, Quarterly Labour Force Survey, QLFS: Q2: 2018 (31 July 2018), http://www.statssa.gov.za/?p=11361, accessed 24 January 2019.

47 J. Parle, ‘Obliv[i]on C: Sedatives, Schedules, and the Stresses of “Modern Times”: South African Pharmaceutical Politics, 1930s to 1960s’, South African Historical Journal (this volume); T. Waetjen, ‘Opium between Empire and Colony: Global Drug Politics in Southern Africa, c. 1880–1930’ (this volume).

48 Anon., ‘Health Care Waste under the Spotlight’, ReSource, 11, 3 (2009), 8.

49 Ibid, 11.

50 Ibid.

51 International Narcotics Control Board, ‘Narcotic Drugs: Estimated World Requirements for 2013, Statistics for 2013’, United Nations, New York, 2015, https://www.incb.org/documents/Narcotic-Drugs/Technical-Publications/2014/Narcotic_Drugs_Report_2014.pdf, accessed 14 August 2019

52 Thembisa Waetjen’s article in this volume traces the lineaments of opium’s pharmaceutical histories in South Africa, and in global interconnection.

53 The Single Convention on Narcotics Drugs of 1961 is an international treaty to globalise the classification and regulation of narcotics. As of February 2018, 186 states were signatories. The World Health Organisation and the Commission on Narcotic Drugs are mandated by the Convention to add, remove or transfer drugs among its four schedules.

54 Government Notices/Goewermentskennisgewings, Department of Health, Medicines and Related Substances Act 1965 (Act No.101 of 1965), Schedules. R.1262, 23 November 2018, https://www.gov.za/sites/default/files/gcis_document/201811/42052rg10888gon1262.pdf, accessed 22 June 2019.

55 O. Wiese, ‘The Most Abused Over-the-counter Drug in SA’, Health 24, 16 November 2016, http://www.health24.com/Medical/Cough/Cough-medication/The-most-abused-over-the-counter-drug-in-SA-20150603, accessed 12 January 2019; S. Govender, ‘Over-the-counter Drugs Could be Killing You’, Times Live, 1 September 2017, https://www.timeslive.co.za/sunday-times/lifestyle/health-and-sex/2017-09-01-over-the-counter-drugs-could-be-killing-you/, accessed 22 June 2019; B. Motsoeneng, ‘Codeine: SA’s Over-the-counter Addictions’, Health-e News, 8 June 2015, https://www.health-e.org.za/2015/06/08/codeine-sas-over-the-counter-addiction/, accessed 22 June 2019.

56 J. Reason, ‘How to Make Purple Syrup in South Africa’, 2 February 2016, https://www.youtube.com/watch?v=EX9SAWZ_rvc, accessed 6 November 2017.

57 K. le Roux, ‘Codeine Care: Mitigating Abuse and Misuse’, South African Pharmaceutical Journal, 80, 5 (2013), 47.

58 Interview with pharmacist and owner of multiple pharmacies, East London, 8 August 2018.

59 National Archives of South Africa (NASA), South African Central Archives Depot (SAB), Department of National Welfare (VWN), MAI/D11/26; File named ‘Cough Syrup 1970’.

60 NASA, VWN, MAI/D12/97, File named ‘Cough syrup 1970', 4 November 1970.

61 NASA, VWN, MAI/D11/26, Letter from Braude to O'Malley, 11 December 1970.

62 NASA, VWN, MAI/D11/26, File named ‘Cough Syrup 1970’, including a letter from The Daily News Editorial Department, 6 November 1970.

63 Ibid.

64 Daily News Reporter, ‘Cough Mixture used as Drug’, Daily News, City Late Edition, Durban, 2 November 1970.

65 Private correspondence with Skim, Johannesburg, South Africa, 31 August 2019.

66 Department Of Health, South Africa, ‘Rescheduling of Medicines that Contain Ephedrine’, Medicines Control Council, 27 May 2008.

67 All interviewees have been given pseudonyms.

68 Interview, East London, 11 August 2018; S. Reid, ‘Lil Wayne On Syrup: “Everyone Wants Me To Stop … It Aint That Easy”’, MTV News, 28 February 2008, http://www.mtv.com/news/1582520/lil-wayne-on-syrup-everybody-wants-me-to-stop-it-aint-that-easy/, accessed 22 January 2019.

69 Interview, East London, 11 August 2018.

70 The National Health Act (No. 61 of 2003) states that all patients have the right to confidentiality, echoing the Constitutional protections of privacy (Act 108 of 1996). The guidelines of the Health Professions Council of South Africa (HSPCA) emphasise the imperatives of maintaining patient confidentiality, but also provide particular circumstances in which a patient’s medical information (such as pharmaceutical consumption) may be disclosed, including ‘in the public interest’: HSPCA, Guidelines for Good Practice in the Healthcare Professions: Confidentiality: Protecting and Providing Information (Pretoria: HSPCA, 2006), sections 3 and 4.