Compound Solutions: Pharmaceutical Alternatives for Global Health

Susan Craddock. Minneapolis, MN: University of Minnesota Press, 2017. xiii and 184 pp., notes, bibliography, index. $100.00 cloth (ISBN 978-1-5179-0078-6); $25.00 paper (ISBN 978-1-5179-0079-3).

This forum on Susan Craddock's important new book examining product development partnerships formed to develop vaccines and treatments for tuberculosis was first presented at the 2017 meeting of the American Association of Geographers. As Matthew Sparke's contribution makes clear, Compound Solutions is interdisciplinary, drawing on a wide range of scholarly literatures including not only health geography, but also medical anthropology, critical global health studies, and science studies. This set of reviews provides ample demonstration of the wide-ranging contributions that Craddock makes with this book to numerous fields and scholarly conversations. As Abigail H. Neely points out, Compound Solutions can be viewed as an exemplar of and contribution to political ecology of health. Gail Davies locates its contribution to the new literature on geographies of science. Sparke focuses on insight Craddock offers for those of us engaged in the discussions of neoliberalism taking place across many disciplines and interdisciplines. My own contribution to the forum shows the relevance of the work to conversations in and beyond feminist studies of the political potentials and limitations of nongovernmental organizations (NGOs) and other organized efforts for social transformation. Craddock provides a generous response to the questions and comments offered by the reviewers, explaining her thoughtful and considered approach—the difficult decisions that go into shaping any substantial scholarly project—and reminding us, as the book itself does, of the multivalence and dynamism her ethnographic research revealed.

In Compound Solutions, Susan Craddock investigates initiatives, product development partnerships (PDPs), to produce better tuberculosis drugs and an effective tuberculosis vaccine. She does so in an effort to understand novel forms of pharmaceutical research and development for diseases that primarily affect poor populations. Craddock argues that PDPs—collaborations among academics, NGOs, donors (foundations and governments), and pharmaceutical and biotech companies—give the development of new drugs a decidedly different flavor. Rather than being motivated strictly by profit (a return on investment [ROI] in a solely monetary sense), PDPs are motivated to address a particularly pressing “global health need” (almost always affecting the poor), a need that often promises rather limited return on (monetary) investment. Rather than throw out the idea of ROI all together, Craddock shows that these organizations offer an alternative understanding to justify their expenditures. In this framework, the lives of the poor have equal, if not more, footing than a monetary return: Ethics and profit matter to this double bottom line. Craddock argues that this alternative framing has an effect on all stages of production from scientific practice to regulation to clinical trial design to the new compounds produced. This, she reveals, offers an alternative, if not a complete challenge, to business-as-usual in pharmaceutical production, scientific research, and perhaps even neoliberalism more generally.

As a political ecologist, I find Compound Solutions to be both exciting and generative for understanding health. In the fast-forming subfield of political ecologies of health, scholars see health as the entanglements of biological processes and sociocultural worlds, embedded in broader political-economic structures. Craddock's work, and her rethinking of the pharmaceutical in particular, exemplifies some of the great potential of a political ecology of health approach. This is a masterful story of the bacterium—its wily nature, scientists' lack of understanding of how it works, what it does in the body, how it mutates, how it matters—and of the PDPs—the forming, reforming, and adapting partnerships among researchers at academic institutions and at pharmaceutical companies, those companies and their corporate mandates, funders, regulatory bodies, and NGOs. In this single story we see the entanglements of bacteria and politics, a clear nature–society relationship, all embodied in the end product: the pills and the vaccines. In other words, this is a story about the inextricability of the social world and the material world. This is political ecology of health at its finest.

In Compound Solutions, the tuberculin bacillus is an important actor, driving developments in the best possible, nondeterministic way. This bacterium shifts and changes; it is unknown; and it shapes research, development, regulation and patenting, and clinical trials; not to mention the health of lots of people. It only comes to matter, though, through its relationships with human actors and their institutions, the ones who believe in the double bottom line—profit and people, those who do research, and those sick with tuberculosis (TB). These human and nonhuman actors are then embedded in a political economy where some people are more likely to get this disease than others, and where scientific research is often tethered to profit. Again, although these human, social, and political-economic actors and factors are important, as Craddock reveals, they alone are not enough to understand PDPs, the compounds they produce, and why they matter. After all, part of the reason there has been so little progress on new TB therapies in decades is that the bacteria that causes TB is mind-bogglingly complicated. As Craddock reveals, the bacteria matters, just as the people and their institutions matter. In this example, the inextricability of the biological and the social, a hallmark of political ecology, is clearly on display.

Craddock's understanding of pharmaceuticals and of PDPs draws on the work of science studies scholars who understand relations between nature and society through assemblages. She roots this analysis in the particular political-economic context of production and use. She does so through a meticulously detailed and eminently readable exploration of intellectual property, regulatory bodies, funding and more. This combination of the question of the assemblage with the political-economic structures that shape—but do not determine—the assemblage does more than help us understand TB therapies as nature–society relationships; this approach helps us to rethink the possibilities of late capitalism generally and in the pharmaceutical industry in particular. Indeed, the PDPs Craddock writes about are alternative formations within the pharmaceutical industry, which by their success open up the possibility of more alternatives. I see this as an effort to answer Ferguson's (2010) provocation that we should begin to think about the possibilities within neoliberalism, even if those possibilities don't challenge this political-economic order in its entirety. Craddock's exploration of the PDPs and the products they create offers one answer to this. Although not a call to replace the system wholesale, it seems to me to offer an equally critical and important challenge to the ways we understand late capitalism and neoliberalism, especially as it relates to health and health care in the age of global health.

To close my engagement with Compound Solutions I want to bring together the possibilities of thinking within neoliberalism and the insights of political ecology that Craddock offers. The central tension of the book is one between research and profit, where research is about understanding this hugely complicated bacteria (often through limited funding), and profit is about how to hold both a need to make money and a need to help the world's poor in one pharmaceutical practice at the same time. Put in terms of political ecology, it's about the nature of the disease in relation to the social relations with which it is entangled. Moreover, it is precisely because the bacteria is so difficult and the target population so poor that these new compounds—these novel pharmaceutical assemblages—require a rethinking of profit, a new economic logic. In turn, these therapies are only possible thanks to this new profit motivation, this novel configuration within neoliberalism. This pairing really comes to matter as Craddock explores the central ethical question of the book in the chapter on clinical trials: Who should these PDPs be saving? Whose life is worth investing in? How do nature, people, and profit came together in an ethical world? These questions, so important in global health, are fundamental to thinking about and imagining more ethical worlds today. They are questions embedded in and limited by nature–society relationships, which offer possibilities for reconfigurations of worlds of late capitalism.

If a previous generation of work on the geographies of science looked at locales as the “vital links in the chain of production, validation, and dissemination” (Thrift, Driver, and Livingstone 1995, 2) of scientific knowledge, a more recent body of work focuses on how scientific practices are involved with the production of technological mobilities and spatial inequalities. They have interests in common, but also differences. They both inquire into how power operates through the institutions of science and technology, but now civic spaces of natural history (Withers and Finnegan 2003) are replaced by corporate practices for social responsibility (Barry 2013). There is shared attention to the practical processes of knowledge production and distribution, but instead of charting how regional values shape reception of new ways of seeing nature (Livingstone 2010), global differences are used to understand how value is generated through distributing the risks and benefits of new biomedical research (Rajan 2017). There are parallel interests in how animal bodies are enmeshed in processes of human corporeality and identity, in relation to national identity and histories of race (Anderson 1995) and, more recently, genomics and the promissory potential of personalized medicine (Davies 2012). This reframing of interest in the spaces of science has been invigorated through critical engagement with work on the technologies and capitalization of the life sciences in anthropology, science and technology studies, the bioeconomy, and global health, retaining a keen geographical sensibility to how “facts” travel, their ontological and interspecies entanglements, and the eventful potential of disease situations.

Susan Craddock's book fits broadly within this second wave of work. This short book on pharmaceutical innovation in TB charts the complex interfaces between the politics of global health, the economics of innovation and biomedical knowledge production. The first aim of this review is a clear call to add Compound Solutions to reading lists around the geographies of science, technology, economics, and health. As Birch (2012) suggested, recent work on the economics of the life sciences has too often been separate from study of the spaces of knowledge production. This separation is impossible to sustain in pharmaceutical production, which spans local experimental practices of drug discovery, national safety, and efficacy testing for regulatory science, through to the global extension of intellectual property regimes and drug marketing. The result of these intersecting spatialities is a regime of contemporary drug invention increasingly seen as in crisis (Rajan 2017), unable either to sustain centers of technological innovation or deliver health for millions in the Global South suffering from diseases of poverty like TB. One proposed solution to this impasse is the creation of new global health initiatives called PDPs. Their overriding innovation is in “seeing pharmaceuticals as first and foremost technologies for keeping people alive, rather than tools of profit generation” (p. 4).

How and how far they are working to achieve these ends is carefully traced and makes a compelling narrative. Craddock's text shows that PDPs bring people and practices together: aiding collaboration, focusing funding, and providing a platform for new practices of vaccine testing and drug development. Conceptually, PDPs are used to open up the geopolitical coordinates of contemporary TB: around the financializaton of innovation, the ecological entanglements of disease, and the complex coordinates of licensing, which shape the flows of “informed materials” (Barry 2005) both into and subsequently out from systems of pharmaceutical production, creating value from biologic and molecular entities. PDPs also work as a methodological device, grounding this complex multisited ethnography, and highlighting the operation of humanitarian values within the multiple spaces of pharmaceutical production. Craddock uses the PDP to stage a conversation with the variable cultures and a diverse cast of sympathetic characters in pharmaceutical development. This resulting text is both generous and carefully situated. The focus is on evaluating this policy innovation on its own terms, moving away from reflex critiques of the technological fix, and keeping socioeconomic contexts in play. Critically, her argument is that the goal of PDPs—developing low-cost therapy for millions in need—requires an entirely new kind of pharmaceutical product, with alteric potential throughout the chain of pharmaceutical production, development, and distribution. The question then becomes whether they deliver on this potential. As the narrative of the book unfolds, we see how they “continuously negotiate the exact terms of their alterity as they strive to realise their mission” (p. 6).

If you want to find out the ending, you will have to read the book, and make your own judgment. There will be differences of opinion. These do not detract from the value of the case study; rather, they signal the significance of the wider conversations in which it is located. The second aim of my review is to add just two points to this discussion: “upstream” debates in drug research and development on animal models and translational biomedical research and “downstream” comments on the potentially alteric ambiguity of PDPs across different contexts of health care and delivery.

Processes of attrition in pharmaceutical development have been most visible in human clinical trials, for this is where failures are most public and costly. The design and ethics of clinical trials are a key component of Craddock's evaluation of the alteric value of PDPs, for changes here can refigure how risks and benefits are understood and distributed, whether to health or profit. Failures of translation are increasingly being tracked upstream, however. Managing these sooner in the pipeline—in preclinical in vivo and in vitro research—might both be less expensive and have ethical gains in terms of more effective clinical trials and less animal wastage. Craddock effectively maps issues around animal models in TB. It is a complex condition with no single animal model; rather different animal models are considered partial: Some are better for vaccines, others for drug development, some help understand disease pathways, and others model transmission or host restriction and interactions. Despite these particularities, there are many similarities between Craddock's account and the scientific, market, and regulatory failures to translate animal research in other fields, including highly capitalized areas of science and medicine, such as genomics and behavioral research. Here, too, there are both failures and experiments that are too slow to fail; of pharmaceutical pipelines in apparent crisis; of diminishing returns on both scientific endeavor and financial investment.

The problems Craddock locates within pharmaceutical development increasingly extend into other areas of biomedical science in which “no-one is incentivized to be right” (Horton 2015, 1380). There are related concerns upstream around the financialization of credit and incentive structures, difficulties in modeling complex environmental entanglements across diseases, and problems of information flow and reporting bias mirror later limitations around data sharing and licensing. More positively, many of the solutions PDPs proffer—of new forms of collaborative working, scientific innovation, and open knowledge exchange—are being rolled out elsewhere, too. This raises the question of how far these changes are driven by PDPs alone and how far they are part of a wider efforts to recognize and address failures in scientific reproducibility and translation in the pharmaceutical industry.

Given this convergence, and if the focus is on keeping people alive, perhaps this distinction is insignificant. The ambiguous alteric potential of PDPs might also be tracked downstream, however. In concluding, Craddock explores how PDPs bring transformative opportunities in national health care contexts, bringing with them “bottom-line rules of affordability and access” (p. 132). As PDPs move globally, are negotiated in, and engage countries such as China and India, the argument is that they can enhance local capacities for meeting critical need. Linking new licensing agreements with local trial site development brings the potential for more equal partnerships and the coproduction of new therapies, as well as “potentially formulating norms and requirements better suited to regional economic, social and political contexts” (p. 136). This closing point takes us away from the creation and circulation of value through the spaces of science and perhaps back to the earlier geographies of knowledge that stress the significance of local values in shaping reception. It reminds us that there are still critical questions here. Although the book demonstrates how PDPs can be important political devices in global health contexts where affordability and access are low, in European contexts, where historic commitments to socialized medicine are now being undermined by the withdrawal of state funds and the opening up of commercial opportunities in public health and social care, the ripples might have different effects. These places are not the specific focus of PDPs, but they are key sites for the extension of creative finance mechanisms in health. Further work to evaluate PDPs as a policy transformation might require us to engage across these geographies of science, building on Craddock's excellent work on the transformations of pharmaceutical spaces and global health, to understand the implications for the wider regional geographies and locales that continue to shape the geographies of science and health.

Susan Craddock's innovative and rigorously researched new book begins by underlining the seriousness and vast scale of the global disease burden presented by TB. She reminds readers that about 1.5 million people die from this preventable bacterial disease every year. Global efforts at bringing the rates of infection and death down are making slow progress, and the United Nations has made ending TB one of the main Sustainable Development Goals set to be achieved by 2030. To reach this goal and with 4,000 people still dying every day due to the disease, new solutions are desperately needed. Compound Solutions provides insight into one of the most significant global health responses to date: the philanthropically sponsored development of new vaccines and treatments for TB, along with all the associated scientific and political-economic experimentation. Craddock focuses on how these experimental efforts have taken shape in the form of PDPs between pharmaceutical corporations, governments, university researchers, and philanthropic donors. Empirically examining what she calls “humanitarian pharmaceutical production” in two particular PDPs—TB Alliance and Aeras—she models a way of studying recent developments in global health more generally.

Craddock's approach is remarkably interdisciplinary. She draws together some of the big concerns in health geography with inequality and the uneven global embodiments of neoliberal globalization with critical insights from medical anthropology and a series of questions, cautions, and lessons being developed at the intellectual intersection of work in global health and science studies. From the advances made by Gerry Kearns, Simon Reid-Henry, and Bronwyn Parry in geography, to the work of João Biehl, Johanna Crane, Joseph Dumit, Jim Ferguson, Aiwha Ong, Adriana Petryna, Kaushik Rajan, Peter Redfield, and Anna Tsing in anthropology, to global health practitioner-scholars such as Paul Farmer and Salmaan Keshavjee, the citational circles of the book are inclusive and instructive. It is the work Craddock does in synthesizing these inspirations to come to terms with the pharmaceutical syntheses of PDPs, however, that is the most innovative contribution of the book. She shows that humanitarian pharmaceutical production moves in complex ways beyond the basic underlying economic obstacle—the preoccupation of pharmaceutical companies with profits—that has traditionally led them to avoid investing in new medicines for a disease that afflicts the poor. Compound Solutions thereby provides readers with insights into how PDPs are pioneering at least three significant developments in (1) the molecular encoding of political-economic innovation and hope; (2) the philanthro-capitalist reworking of patent regimes; and (3) the related derisking of involvement by pharmaceutical corporations in tackling health problems such as multidrug-resistant TB (MDR-TB) that their own for-profit interests have helped to create in the first place. In offering these insights, the book is suggestive of some fascinating new foci for geographical research, and it also provokes critical questions about what Craddock refers to as a shift in the “ontological mooring” of neoliberalism (p. 5). Before turning to these geographical suggestions and critical provocations, though, more needs to be said first about the other three areas of insight.

Informed by both Barry's arguments about pharmaceutical invention and Mol's ethnographies of medical practice, Craddock examines the medicines being developed by the TB Alliance and Aeras as encodings of a whole series of political, economic, philanthropic, and scientific practices. She argues on this basis that the PDP vaccines and treatments constitute fundamentally different types of materials from those developed under the normal for-profit imperatives operating in the pharmaceutical industry, thereby constructing molecules of hope. “Thus the rich legal and economic information contained within the molecules of new tuberculosis therapeutics,” she explains, “distinguishes them in critically important ways from their commercial pharmaceutical counterparts. Drug and vaccine candidates possess within those environments a great deal of social, political, and promissory capital. But they also contain hope” (p. 88). Craddock acknowledges that there is still a powerful ROI logic at work in the decisions and direction of PDP research. Accountable to a bottom line that is more about counting the number of lives saved than money made, however, she also suggests that its hybridized humanitarian business model leads to some significant shifts that are distinct from business as usual in the pharmaceutical industry.

The distinctions of the molecules of hope identified in Compound Solutions are subtle but clearly conveyed by Craddock. There is, she explains, more interest in PDPs in developing materials that are hard to commercialize such as vaccine candidates, and there is much more concern with upstream science on the immune system than just with downstream therapeutics. She notes that PDP research can involve conducting clinical trials with subject populations such as children that are commonly ignored in commercial drug trials. She further highlights how it can lengthen the time horizons normally associated with the commercial rush to approve, distribute, and sell new drugs, even though this raises tough questions about saving lives in the present under the emergency imperatives that simultaneously underpin the humanitarian ROI logics.

Complicating or at least complementing ROI logics, Craddock highlights how the contributions of PDP research to upstream science are also leading to enquiries into such social determinants of health such as “how chronic undernutrition might impinge on drug metabolism or why some forms of deprivation negatively impact immune systems more than other forms” (p. 88). Thus, although the investments of global health philanthro-capitalists such as Bill Gates are often critiqued for being preoccupied with finding pharmaceutical fixes at the expense of neglecting health systems and downplaying social determinants, Craddock indicates that PDP research sponsored by the Gates Foundation can still help uncover some of the compounding problems that the compound solutions of humanitarian pharmaceutical production will not be able to solve on their own. That said, she also notes that PDP leaders are painfully aware that the further they stray from biomedically saving lives in the present the more they will have to turn to other funding sources beyond the Gates Foundation, including, however ironically, by turning a “low profit” on their own pharmaceutical innovations (pp. 54–56).

Adding further insight into the nonprofit turned low-profit complexities and compromises of global health humanitarianism, Craddock's research is equally nuanced in its treatment of the impact of philanthro-capitalist investment logics on traditional patent regimes. PDPs, she explains, do not reject traditional patent regimes in favor of wholly public commitments to open access science; nor, it turns out, are they necessarily against monopolies. Instead they are interested in using patents “to ensure low rather than high prices, and to preclude other companies … from usurping … [their] political-humanitarian purpose” (p. 41). The bottom line, Craddock explains, is that “PDPs do not function along the approach that everything they produce will be part of the commons; they control what they produce, but in a particular way—that is to ensure their products remain affordable” (p. 29). These insights come after some useful reminders near the start of the book of how traditional patent regimes can inhibit collaborative research and data sharing in universities due to the patenting of scientific processes, delivery methods, and organisms. Coming from an author who has elsewhere been highly critical of how patents led to the unnecessary deaths of poor people worldwide to AIDS, they highlight how much the hybrid practices of PDPs shift the terms of debate. Clearly Craddock is as impressed by the political-economic innovations of PDPs as she is by their scientific experimentation. For the same reasons, she is candid in telling us that she is also sympathetic to the alternatives indexed in the subtitle of Compound Solutions. “I don't think I could have undertaken the research for this book,” she says, “without fundamentally believing in what these PDPs and their partners were trying to achieve” (p. 29).

As sympathetic and as impressed as she is by the PDP shift away from the traditional use of patents to extract monopoly rents, Craddock is nevertheless keenly attuned to the contradictions and ironies that are involved as well. It is in this way that she critically calls out how corporations involved in the PDPs benefit from the corporate social responsibility (CSR) halo effects of humanitarian pharmaceutical production. “It is sadly ironic,” she complains, “that pharmaceutical companies might now profit socially if not financially from the disease burdens they helped create through their strident pursuit of pharmaceuticals with hefty financial returns to the neglect of public health” (p. 58). She also highlights the problematic ways in which corporate bottom lines benefit from all the derisking work done by PDPs. She shows how these efforts to involve business can backfire—such as in the case of Johnson and Johnson's subsidiary Janssen, which worked with the TB Alliance to bring a drug for MDR-TB to market only to then price the drug—bedaquiline—so high that it was completely unaffordable for the populations most vulnerable to MDR-TB (p. 39). In a fascinating example involving the reverse of “evergreening” (the drug company tactic of extending patents by mixing previously patented drugs in new combinations), Compound Solutions proceeds to outline how TB Alliance is also pioneering a work-around to overcome Janssen's overpricing by developing a multidrug regimen that contains bedaquiline but that is sufficiently novel as to claim a new patent (p. 40). The resulting regimen is thereby explained as being targeted by the PDPs both biomedically and in terms of the economic geography of pricing at the same time.

The effort to make TB drugs affordable and to do so in a way that takes account of what particular populations in particular locations can pay is just one of the interesting lines of geographical research opened up by the book. Compound Solutions highlights how PDP plans and practices are thereby reversing the problem that economic geographer Christophers (2014) described of drug companies systematically failing to honor their CSR commitments to tiered pricing. This invites further geographical study into how the PDP plans and practices divide up the world into segmented markets, something that is especially interesting when it comes to large countries such as China, India, and Brazil that are the location of some extremely poor and vulnerable populations at the same time as being home to significant middle-class and wealthy communities that are the more typical targets of pharmaceutical marketing. Relatedly, Compound Solutions highlights how another reason corporations might partner with PDPs is that the resulting ethical “halo” can open access to large and fast-expanding new markets. These kinds of market access strategies by drug companies would seem in turn to invite more study by economic geographers interested in the increasingly complex ways transnational corporations (TNCs) organize their global value capture networks. In this respect, Craddock's careful attention to the extraeconomic codings of “value” in PDP value chains additionally offers invaluable insight for scholars of value theory more generally (especially, I would submit, those interested in the spiraling dialectics of value that can be traced from Marx through the open-ended rereadings of abstraction offered by Diane Elson, David Harvey, and Gayatri Spivak into the molecular searches for surplus surveyed more recently by Melinda Cooper and Kaushik Rajan).

In addition to the interwoven economic geographies of patient access pricing and TNC market access, other interesting geographical research topics opened by Compound Solutions include the impact of climatic conditions on drug testing and vaccine delivery strategies (p. 72); the less spatially enclaved outcomes (in terms of lab openness and access for fellow scientists) of the PDP commitments to collaborative upstream research and data sharing (p. 76); and the need to locate trial sites in high-burden countries and to engage meaningfully with local communities in terms of research organization as well as benefit sharing (chapter 3). Given the ongoing concerns in critical geography with neoliberalism, however, there might be still more interest in Craddock's argument that PDPs “are forcing a shift in the ontological mooring of today's market-driven neoliberal pharmaceutical industry” (p. 5). My concluding suggestion here concerns how we might come to terms with this shift.

Craddock acknowledges the enduring impacts of market fundamentalist neoliberalism in shaping the terrain in which PDPs confront TB: including the widespread financial precariousness of the populations and governments dealing with the disease, the related undermining of commitments to government-organized universal public health protections made at Alma Ata in 1978, and the now normalized proprietal approach brought to research by many scientists. Compound Solutions also points to some significant breaks with market fundamentalist neoliberalism made by PDPs, however, in the interests of expanding affordable access to new treatments and vaccines. Craddock's account of these developments highlights how they still involve compromises with market power and market practices that leave big pharma with big monopolies. Yet following Ferguson in cautioning against the knee-jerk condemnation of all things neoliberal, she suggests that such compromises might well be worth making in the interest of saving lives. I think this is an extremely important political question with which all critics of neoliberalism need to engage. Craddock is courageous in stating her own sympathy for the work of PDPs as clearly as she does, but in eschewing the presentation of another broadside against neoliberalism she does not articulate as clearly as she might the ways in which a new neoliberalism is being consolidated through such philanthro-capitalist contributions to global health. Elsewhere, Mitchell and I have suggested that such a revised neoliberalism departs from market fundamentalism by cohering around what we called a New Washington Consensus on correcting macromarket failures with micromarket interventions (Mitchell and Sparke 2016). In this respect, and insofar as Compound Solutions presents multiple examples of such micromarket interventions in the microbiological form of new molecular investments, experiments, and hopes, I would like to suggest that it seems to corroborate the argument that a New Washington Consensus is increasingly influential in governing the future of global health.

Unlike the other contributors to this forum, my reading of Susan Craddock's Compound Solutions is not grounded in health geographies or critical global health studies. Rather, I come to this important new book having participated in the transnational feminist cultural studies critique of NGOs (Kaplan and Grewal 1999). I come to it as a theorist of complicity (Joseph 2002, 2014). That is, I am particularly interested in Craddock's discussion of the PDPs as not only innovative but politically complex and contradictory entities, implicated in and dependent on the very systems and structures that produce the problems they seek to solve. I am particularly impressed by her risk-taking argument that positive outcomes follow from the complex relationships among diverse actors that PDPs work to develop and sustain.

PDPs are not NGOs, although they include NGOs as partners; in fact, they challenge the tripartite sectoral framework (government, for-profit, nonprofit) that generally shapes scholarship on nonprofits and NGOs. A brief account of the trajectory of the feminist critique of NGOs, however, helps to reveal a significant aspect of the contribution Craddock makes through Compound Solutions.

NGOs have been of interest to transnational feminist cultural studies in part because that organizational form has absorbed so much feminist energy over the last several decades. The primary lines of feminist critique note that NGOs play a role as soft-power supplements to official governmental military, diplomatic, and economic projects; as often but not always explicitly religious missionary organizations, NGOs are key players in cultural as well as economic and political colonialism and neocolonialisms. Although NGOs might provide aid to the needy or enhance well-being in various ways, they are a key mechanism for preserving and protecting capital accumulations. (The Gates Foundation, which plays such a central role in Craddock's story and is funded by two of the world's richest men, Bill Gates and Warren Buffett, echoes the capital preservation strategies of earlier cohorts of superaccumulators such as Carnegie, Rockefeller, and Ford.) NGOs are also of interest in so far as they engage people in their local relations, their communities, and cultural practices, often reinforcing gender, race, and class hierarchies, even as they draw individuals and communities into neoliberalism by shaping subjects as personally responsible entrepreneurs of their lives.

The discussion of NGOs among feminist scholars has progressed to the point where the initial assessment of their complicity in all things bad is being nuanced and revised. Some feminist critics are recognizing the multivalence of the work of NGOs, some of which resist even as they participate in neoliberalism, create and disseminate feminist knowledges, and actively respond to the earlier critiques by revising their own processes and practices. As evidenced by the edited collection Theorizing NGOs (Bernal and Grewal 2014), scholars are noticing that some aspects of the radical critique depend on idealization of and nostalgia for prior activism or social movements. Instead, they recognize the inevitable impurity of our activist tools (including organizational structures, such as the NGO form) and urge us to work to make them “unfaithful to their origins” (Hodžić 2014, 231).

We can understand the organizations on which Craddock's study focuses, the TB Alliance and Aeras, as well as her approach to and assessment of those organizations as situated at this nuanced point in the history of organizations and our scholarship about them. Having conducted extensive ethnographic work with those involved in all aspects of these partnerships, Craddock offers wonderfully rich descriptions of the particular cases, which is exactly what is necessary to forestall any too quick identification of good guys and bad guys. Craddock calls the TB Alliance a “virtual” organization in that it does not have its own brick-and-mortar research or production facilities, but rather contracts with academic and private-sector researchers and with biotech and pharmaceutical companies. Aeras has a greater brick-and-mortar dimension but nonetheless is quite liquid in organizational form: It grew out of a for-profit firm but reorganized to be able to take up a funding offer from the Gates Foundation, also a primary funder of the TB Alliance. Craddock's investigation of PDPs shares with the best new work on NGOs the ability to perceive dynamism, multivalence, and potential for unfaithfulness to origins.

Surely, it would be easy enough to cast PDPs as complicit. Their proclaimed missions are as Craddock calls them humanitarian in that they seek to solve a huge public health problem by creating vaccines and treatments that are accessible, affordable, and available. These are entities, though, that, through leadership structures, vision, and discourse, reiterate the hierarchy between Global North and Global South. They can be criticized for taking up the problem as a technological one, despite the great evidence that it is poverty and global political inequality that distributes and sustains tuberculosis. They depend on funding from foundations that preserve and extend the power of huge accumulations of capital; and they include as part of themselves corporate for-profit pharmaceutical company partners, whose mission is capital accumulation. As Craddock argues, the for-profit pharmaceutical companies' rationales for participating in these partnerships are generally transparently self-interested—that is the companies participate because they can see that it will serve their profit-making goals. On one hand they are fulfilling an imperative to CSR, a mode that can often, as Craddock argues, be criticized as merely public relations and lacking in substance. What is more interesting, though, is where pharmaceutical company participation is substantive, a means of extending corporate power. Craddock says, “Those with whom I spoke from the corporate sector openly discussed the short- and long-term marketing benefits of TB initiatives but also talked about imbrication—not contradiction—of new market strategies with social missions to better address diseases of poverty.” (p. 63). By building relationships, such as in and with China via TB initiatives, they will open up new relationships and markets for more profitable drugs. They must also often include as part of themselves governments at various levels; this is not just about working through policy and regulatory processes for drug approval, but also finance, as both of these organizations develop relationships with China as a source of financial support that might displace or replace Gates.

As I have argued elsewhere, however, tracking complicities, which is to say, tracing relationships, should only be the beginning of the project. Relationships are multivalent or at least can be mobilized for different purposes—I have even suggested that we have a responsibility to mobilize them for different purposes once we recognize our implication. The primary function of PDPs, as Craddock presents them, is to organize and manage relationships, relationships among funders, drug researchers, and producers in their various for- and not-for-profit situations (commercial and academic), as well as the national and local governments, and the potential participants in clinical trials in various locations, reachable through health agencies and political organizations. One of the richest aspects of the book is Craddock's detailed description of particular relationships—such as drug company Janssen's participation in the TB Alliance. She emphasizes through this case and others the tenuousness of these relationships, but suggests that we focus on the moments of success rather than failure. Craddock's argument then is precisely that relationships are being mobilized for different purposes. In effect the corporations are being made complicit with a humanitarian project despite themselves.

Craddock argues that technological intervention is not entirely separable from the political-economic intervention that a more purely anticapitalist project might want to undertake (and moreover that it would be unjust to refuse to work on the technological intervention while waiting for the revolution). For instance, although the ethical complexity of clinical trials is truly awesome and surely one could read the processes by which trial participants are recruited as a recruitment to neoliberalism, Craddock suggests that we also recognize that their unusually substantive engagement with participants as well as their approach to staff education are steps in the direction of political economic intervention. Craddock persuasively argues that not only are these partnerships effectively getting drug research moving where it had stalled out, but they are also developing new approaches to research and development. Among these are a revaluing of failure in the research process, somewhat more open sharing of knowledge among researchers, and emphasis on process costs rather than isolated evaluation of most effective treatments.

These complex entities might be understood less as NGOs or even some creative new hybrid organizational form and more as financial instruments, along the lines of the derivative, that temporarily isolate and affiliate particular aspects of a given asset for a particular purpose. If we view them this way, then it is easier to join Craddock in recognizing and valuing their positive, if impure, outcomes.

Before responding to the fabulous points raised by Sparke, Neely, Joseph, and Davies, I want to thank these busy individuals for agreeing to read my book with the care and consideration they clearly employed, and for their enthusiasm for my work. I already know that I won't do justice to their insights, even though I agree with the questions they raise about the role of PDPs in larger scientific efforts (Davies), and within broader contexts and configurations of late twenty-first-century capitalism (Neely, Sparke, and Joseph). Indeed, from the beginning of this project I thought continuously about how I would frame the role PDPs played in both of these contexts. Why not, for example, broaden my analytical remit and take as my subject the multiple forms of collaborative scientific endeavors ongoing or incubating in various venues—the question Davies aptly raises? Going this route undoubtedly would have provided a more encompassing glimpse into “wider efforts to recognize and address failures in scientific reproducibility and translation in the pharmaceutical industry,” as Davies puts it. Such a glimpse would have included the ability to cross-compare the strategies, locations, financial mechanisms, and missions these various efforts embraced, and to consequently analyze which if any approaches more effectively pushed back against pharmaceutical failures.

My answer to this important question is multifaceted. First, I wanted to focus on those formations dedicated to researching drugs and vaccines for diseases with some of the highest burdens globally. Second, correctly or incorrectly, PDPs appeared to me to be the biggest players within the field of alternative pharmaceutical research and development, and as such, would more likely pose the best chance of transforming—or at least partially reconfiguring—pharmaceutical spaces. As is so often the case in the issues we endeavor to untangle, I also opted for greater depth into one alternative formation and the detailed insights this would proffer, over greater breadth and comparative advantage. Having said that, the PDP collaboratives I examined partnered with, or participated in, several other endeavors including GlaxoSmithKline's (GSK) Open Lab, the Netherlands-based Tuberculosis Vaccine Initiative, and the Critical Path to TB Drug Regimens, thus allowing me to investigate these other alternative formations in their own right but also as extensions of PDPs. My sense in seeing the collaboration of these collaboratives was that if continued they could achieve the greatest transformative potential, one that—like the saying goes—could be more than the sum of its parts.

My biggest regret in this regard, perhaps, is ultimately realizing that my original intention to focus on both malaria and TB PDPs was too ambitious if I was going to go into the depth that was my aim. One reason for wanting to take on both of these complicated diseases was to see the difference that a vector-borne parasite made versus a bacterium in the possibilities and limitations for new pharmaceutical development. As Neely points out, I was keenly aware from the start of the important role pathogens themselves play in virtually every facet of global health initiatives—from philanthropic attention, PDP funding, the extent of scientific knowledge, and the parameters to pharmaceutical development. Like TB, malaria historically has proven to be a highly tenacious foe of public health initiatives not only because of the complexity of the parasite, but also the wily survivability of the mosquitoes transmitting it. The political and pharmaceutical ecologies, thus, would have been instructively different from those of TB, but time simply did not allow pursuit of both.

I got far enough in my malaria investigations, however, to see that malaria partnerships were both similar to, and different than, those of TB. PATH's Malaria Vaccine Initiative funded largely through the Gates Foundation very much resembles the kinds of partnerships forged by TB Alliance and Aeras in, for example, supporting GSK's development of a new malaria vaccine, RTS,S. GSK was unlikely to go further in developing its malaria vaccine without supplemental funding to subsidize expensive Phase III clinical trials; like the incentivization necessary in TB PDPs, then, PATH's support was critical to bringing the vaccine through that critical juncture. A very different malaria collaboration, however, was evident in the Drugs for Neglected Disease initiative (DNDi).

. Although the DNDi's efforts were limited to finding more effective drug combinations from drugs already on the market, it nevertheless showed critical divergences from many PDPs in working only with countries and pharmaceutical companies from the Global South, and accepting financial support from individual donors while eschewing philanthropic largess. The merits of this admirable initiative, as well as its limits, are further discussed in my Social Science and Medicine article titled “Precarious Connections” (Craddock 2015). That article, when combined with the book, goes some small way in addressing Davies's point that more studies across geographies are needed—a point with which I wholeheartedly agree.

What connects all of these formations, however, is their unequivocal conviction that technologies hold the answer to improving the lives of the poor in resource-deprived countries around the world—a point that brings me to the role of PDPs in global health initiatives and, consequently, in current coordinates of global capitalism as mentioned in particular by Sparke and Joseph. This is a point that has been the trickiest to navigate, and one that frankly will never have a satisfying answer because, to put it bluntly, there isn't one. We do inarguably live in an era of increasing economic inequalities, human rights infractions, poverty-induced migrations, and inordinately powerful corporations—including Microsoft, the company that made Bill Gates one of the richest individuals in the world through its infamously competitive tactics and its highly controversial strategies of overworking and, at least in overseas Chinese factories, grossly underpaying its workforce. Hence the hypocrisy cited by many critics of global health initiatives in seeing the Gates Foundation funding humanitarian projects.

The criticism is absolutely correct. Where does that get us, though? Not surprisingly, from the very beginning of researching this book I have received critical questions from colleagues pointing out my complicity in supporting the wreckage of neoliberalism by writing about initiatives relying on pharmaceutical companies and philanthropists like Gates directly responsible for at least part of the wreckage. My answers to these—and to Joseph's apt point about the circulations of knowledge that are a part of complicity—are first to point out that I am not, in fact, extolling PDPs, but rather asking a range of questions about their potential to still achieve positive change despite the source of their funding, and about whether they could even make more apparent the specter of pharmaceutical industry violence by the very necessity of their existence. My statement that I could not have written this book had I not believed in what PDPs were doing was not an endorsement of PDPs, but rather of their mission. This leads to the second answer, which is that PDPs are not pushing out effective government-led initiatives to develop drugs for diseases like TB. These have not existed for decades, nor will they likely appear any time soon when many governments are swinging to the right and the private-sector celebrations this typically entails. To Davies's point, governments like those in the United Kingdom and United States are eroding what should be a right to health and health care for their own populations, allowing pharmaceutical companies ever more rein to drive up drug prices to the point of unaffordability even in the wealthiest countries. Joseph's comment that my book tacitly asks whether good things nevertheless might happen while we wait for the revolution, or at least for the tide to turn, is indeed apt.

Joseph's point that she sees PDPs not so much as NGOs but as “financial instruments … that temporarily isolate and affiliate particular aspects of a given asset for a particular purpose” is not entirely off target. PDPs have indeed been deft at getting partners to work with them, including pharmaceutical companies. They have made these companies complicit with humanitarian projects, but as I make clear in the book, pharmaceutical industry involvement is one of the weakest yet most necessary links in PDP endeavors. This is why I think that the best bet for PDPs is for them to succeed in their attempts to continue forging partnerships with emerging economies like India, Brazil, and South Africa, in addition to the partnerships they have in China. Working with these countries' well-trained scientists and pharmaceutical sectors theoretically would be an easier sell given these countries' high burdens of TB, and given government commitments at least in principle to ameliorating those burdens. In the best case scenario, these partnerships might even prefigure the demise of PDPs if they succeed, and each country becomes the regional distributor of effective vaccines and fixed-dose combination drugs. That would be a demise worth working toward.

To Sparke's question of whether PDPs are part of what he and Mitchell call the New Washington Consensus, my answer is both yes and no. Under the overarching celebration of the so-called free market and what it is capable of is a more mixed sense of purpose—a more complicated layering of values and perspectives—for those involved in initiatives forged within this ideological crucible. Scientists are a good example. Many have left more lucrative jobs to work on developing TB drugs and vaccines, or they see PDPs as the chance to advance—finally—the work on TB they've been invested in for years with no mechanism to get it further down the pipeline. These individuals are not so much entrepreneurial as idealistic. That they would technically be creating better and more neoliberal subjects if they succeed in saving thousands from an incapacitating if not fatal disease, which then means more individuals (theoretically) working jobs that will enable them to purchase more commodities is one way to look at it. This is not the way scientists see it, though. Their efforts instead signal their belief in the potential of science to alleviate unimaginable burdens of suffering; and although this clearly includes a blind runaround of the elephant in the room that drugs or vaccines alone cannot alleviate the poverty continuously producing tubercular subjects, I nevertheless wish far more scientists had such humanitarian impulses.

I could go down the line and articulate the reasons, hopes, and ambitions of everyone involved in PDP initiatives, down to the participants who proclaim their desire for the next clinical trial for themselves or their infants. The point is not to stop at Bill Gates when evaluating initiatives funded by the Gates Foundation. Only when everyone enmeshed in these initiatives is included in the evaluation can the incredibly dynamic, emotive, symbolic, entangled, politically complex variability begin to be teased out. By that time, it seems a long way from Washington or from anything resembling a consensus.

ORCiD

Gail Davies http://orcid.org/0000-0002-6811-0885

Miranda Joseph https://orcid.org/0000-0001-6643-458X