The territorial/political border is a place of residence for people who, due to forced displacement or migration, are en route to the United States. Conditions are determined at a macro level by the pressure exerted by both Mexican and United States immigration policies;15 sex work becomes a strategy for making enough money to be able to continue the journey with fewer risks to physical safety by avoiding becoming victims of organised crime or deportation. In this regard, the number of deportations to Central America from the United States has exponentially decreased, while deportations from Mexico have increased (MIV 2015). The first immigration control point is located in Tapachula, constituting an initial fixed border that extends into a *mobile* border across the Mexican territory. The fixed border in Tapachula is a preview of the persecution to which migrants will be subjected due to their undocumented status.

At the same time, the border is also symbolic, consisting of the discriminatory prejudices held by a large sector of the local population about migrants from the Central American northern triangle, who, though historically considered an essential part of the region's economy and workforce, remain a vulnerable social group (Leyva and Quintino 2011). Local social prejudices are also present in Ciudad Hidalgo and Tecún Umán, linking migrants to crime (especially theft) and drug addiction (Canales et al. 2010).

The policies that led to current pressure by immigration authorities in Mexico and to the creation of the aforementioned stigmas promote the criminalisation and stigmatisation of migrants; they are related to the Mérida Initiative (2008) and Plan Frontera Sur (2014). Both these intergovernmental policies are indicative of the post-9/11 paradigm change and the development of a security strategy based on containing and thwarting migration (León Hernández 2011). A number of studies demonstrate the devastating effects of both policies in terms of immigration containment, leading to an increase in systematic violations of the human rights of migrants, especially in certain regions of southern, eastern and north-eastern Mexico. By fuelling the perception of insecurity, these policies undoubtedly seek to reduce the flow of migrants (Correa-Cabrera 2014).

The so-called 'war on drugs', based on military strategy, unleashed a proliferation of drug use in Mexico, as well as an increase of violence there and, as an extension of the conflict, in Guatemala and other Central American countries (ACAPS 2014). This scenario of violence and conflict is exacerbated by a lag in adopting policies decriminalising drug use, as is the case in Guatemala (Colussi 2013), and by failure to reduce social stigma and discriminatory treatment towards drug users by authorities and the local population16 which leads migrant drug users to be subjected to various symbolic borders that make them resort to segregated spaces for drug purchase and consumption.

In addition, this policy lag removes otherness from common public spaces, thereby concealing this marginalised population from the local population in two ways: through *puntos*, as an intersection between purchase and consumption, and through *pasos*, which are linked to spaces for consumption near locations of informal work17 to which migrant drug users are relegated, and often serve as an extension of informal shelters, condemning them to destitution. *Pasos* and *puntos* are socio-spatial phenomena characteristic of the Mexico–Guatemala border; yet *puntos* are also present in various Central American countries (Dickson-Gomez et al. 2012), but absent in other contexts of southern Mexico. Why? We believe that this is a compelling question for further research.

Stigma and discrimination against low-income, drug-using migrants function explicitly or implicitly by generating separate spaces on the basis of both factors of vulnerability; these spheres have uses and consequences in common with the non-drug-using migrant population as well as the local drug-using population. At the same time, these areas are also characterised by the juxtaposition of the symbolic and material marginalisation of both conditions – poverty and drug use.

The border is a place for transit that functions as a space for shelter, insofar as the current political logic imposes sojourns and territorial extensions by means of legal threats (deportation) or illegal ones (organised crime). In this context, stigma and discrimination against migrants and drug users operate through structural and symbolic mechanisms of exclusion from the formal job market and become determinants of health by increasing vulnerability to HIV contraction through risky sexual practices during sex work.

In this regard, an analysis of the triad 'border–*puntos*/*pasos*–body' explains the political dimension of a type of violence that can be defined as socio-spatial, and is characterised by its ability to transform those three elements. In other words, physical and symbolic spaces of inclusion and, as we have seen with *puntos* and *pasos*, exclusion – understood as social constructions produced by the local impacts of immigration policies and regulations on drug use and trade – are inscribed in the bodily economy of sexual practices' exchange value at the intersection of the subject's country of origin, social class, ethnicity and sex/gender identity.

The reifications of the body and the social space (in the terms of Bourdieu 1999) at the Mexico–Guatemala border, and along the mobile border with the United States in Mexico, are pre-existing conditions that transform and influence one another. The porous geographical border between Mexico and Guatemala also becomes a mobile border located within a network of non-static and non-linear geographical and symbolic points throughout Mexican territory, with its geography of immigration checkpoints, places of exposure to violence and physical or economic extortion by organised crime, and zones of shelter where migrants can obtain money to continue their journey. This geography finds its full expression in these mobile, symbolic and geographic micro-spaces of *borderi*s*ation*, determined and legitimised by an ideological landscape characterised by disdain for migrants' human rights and reinforced by stigma and discrimination; they represent a landscape produced by current migration policies and the threat posed by organised crime. In this context, conditions influencing social vulnerability to HIV infection in Tapachula, Tecún Umán, Ciudad Hidalgo and Quetzaltenango take the form of inconsistent condom use due to the power imbalance between clients and sex workers, and are mediated by informal/formal sex work, clients' gender and sexual orientation, the need for money or drugs, the type of drugs used and condom availability.

The type of sex work influences condom use by the space in which it occurs and its structure, among other factors. Theoretical contributions to the analysis of formal and informal sex work have been undertaken, for example, by Maternowska (2006) and Tabet (2005). Along the lines of these analyses, space determines access to places or to people who have condoms, while its structure, through the target clientele, alters perception of risks, due to homophobic prejudice based on gender and sexual orientation. The aforementioned conditions of discrimination and stigma impact the need for money or drugs and the willingness to engage in unprotected sexual practices, which are in turn influenced by the type of drugs used and amount consumed, making drugs an instrument of compulsion and resistance in unequal negotiations over condom use.18 The evidence produced by this study contributes to elucidating, from an ethnographic perspective, the processes of social vulnerability to HIV for undocumented migrant and displaced male drug users, in a border context where no existing social research currently considers this problem, and where the recent epidemiological study by Conners et al. (2017) reveals a connection between drug use, unavailability of free condoms, occasional sexual encounters and inconsistent condom use.

### Conclusions

Approaches to spaces of production of social vulnerability in processes related to health/illness/care and prevention are enhanced if they are connected to analyses of the macro-structural frameworks that configure them. They also benefit when they are interrelated to local characteristics and to the correspondences and linkages among bodies/subjects, spaces and borderisations in the access to an unequal distribution of symbolic and material resources. In the Mexico–Guatemala border context in general, and specifically regarding AIDS, a so-called epidemic of signification (Treichler 1988), sociocultural and political analyses of spaces of migrant transit illuminate social determinants of health experienced by these migrants, and their strategies and perspectives for addressing them. This analysis challenges discriminatory views of migrants, and in this case migrant drug users, as a threatening blight upon the societies through which they pass or ultimately settle. For this purpose, a relational approach (Menéndez 2009) in critical medical anthropology questions the dialectic of micro-subject versus macro-structure as an opposition, and considers these analytical levels as linkages of the same processes.

Critical medical anthropology allows us to elucidate the effects of global forces and local ideologies on health by examining social practices and representations that occur in specific social relationships. In the present case, these social relationships are cemented through processes that increase the vulnerability to HIV infection, and occur in mobile spaces of territorial and symbolic borderisation that are conditioned by attitudes of stigma and discrimination and amplified through North American capitalist policies. The subjects' perspectives and survival strategies, resulting in exposure to HIV and practices to reduce exposure, do not automatically arise from Plan Frontera Sur or the Mérida Initiative, or the so-called 'war on drugs'. Nevertheless, these programmes, their local consequences and their link to socio-economic and political conditions in this region are co-factors in the updating of the dynamics of north/south dispossession, not only (re)producing but also justifying the misfortunes of other migrants.

This exploratory study highlights the need for ongoing critical medical anthropology studies of these issues at the Mexico–Guatemala border, exploring variables such as ethnicity, age, sex/gender identity and sexual orientation, forced displacement, local consumer networks of drug use/dependence, institutional and organisational programmes for sexual health and addictions, and their relationship, or lack thereof, to the various forms of sex work and exposure to HIV. We recommend further research on behaviours and social representations in spaces where processes producing social vulnerability to HIV occur throughout the mobile border between Central America and the United States, as well as other points of migrant transit through the geographical border between Mexico and Guatemala.

### Notes

### References

Chiapas. Accessed 17 September 2019. http://www.haciendachiapas.gob.mx/marco-juridico/ Estatal/informacion/Lineamientos/Normativos/2017/XXIII-Estadistica-Poblacion.pdf.

### 7 The ethno-racial basis of chronic diseases: Rethinking race and ethnicity from a critical epidemiological perspective

Melania Calestani and Laura Montesi

An engaging five-day workshop on critical medical anthropology organised by CIESAS and UCL was coming to an end. It was a sunny Friday in January and the Central Valleys of Oaxaca promised a spectacle of beauty and historical heritage to a group of anthropologists. We were about to visit Monte Albán, an archaeological site, testament to the Zapotec civilisation and its power over the region. We were still riding the wave of the workshop debates when we met our tourist guide. We introduced ourselves to him and when Laura said that she worked with diabetes patients, the guide observed that diabetes is the largest epidemic in Mexico, caused by an unhealthy food system and by wrong eating behaviours triggering defective genes: 'We, Mexicans, are genetically predisposed to diabetes.'

We looked at each other and immediately understood that we were thinking along the same lines. We had been talking about racialised societies and health during the last few days, having found parallels between our respective works on social representations of diabetes in Mexico, and on chronic kidney disease and kidney transplant listing in the UK. We were wondering about the growing explanatory power of genetic aetiologies in health discourses and about how and why certain social groups, often detected on the basis of ethno-racial differences, end up being described by researchers, physicians and public health workers as genetically prone to many diseases and conditions, including type 2 diabetes (hereafter diabetes) and chronic kidney disease. We had also discussed the ways in which such representations and medical and scientific practices become part of the public imaginary, intersecting with popular notions of race, ethnicity, fitness and weakness.

In the 1990s, Lippman introduced the term 'geneticisation' to describe 'an ongoing process by which differences between individuals are reduced to their DNA codes, with most disorders, behaviours and physiological variations defined, at least in part, as genetic in origin. It refers as well to the process by which interventions employing genetic technologies are adopted to manage problems of health' (1991: 19).

The term geneticisation is resonant with 'medicalisation', which indicates processes 'by which nonmedical problems become defined and treated as medical problems, usually in terms of illnesses and disorders' (Conrad 1992: 209). Although medicalisation can have beneficial impacts, it has traditionally been seen with suspicion by medical anthropologists in light of the tendency by societies to label deviance and use medicine as a means of control, punishment or marginalisation. Finkler (2000) expressed concern about the mushrooming growth of beliefs in genetic inheritance because they are instrumental to the individualisation of health problems and the technification of solutions. Kinship and ethno-racial genetic explanations and solutions sit easily within the current global neoliberal climate and the growing 'economisation' of 'heretofore noneconomic spheres and activities' (Brown 2015: 17). As Marks (2013) highlights, genetic and genomic research projects usually promise solutions, mainly diagnostic tools, which are easily privatised (2013: 257). This raises more than one question about the interests behind scientific research, an issue that is becoming of paramount relevance as public funds diminish and corporations are increasingly being subsidised by state governments to promote research and provide health services (Clarke et al. 2003: 167).

To disentangle how political and economic forces shape scientific research and medical practice, we draw on Breilh's critical epidemiology (CE), which serves a double purpose: it supersedes the limits of conventional epidemiology with its multi-causal (yet still lineal) model of disease and rethinks 'health as a complex, multidimensional object, submitted to a dialectical process of determination' (Breilh 2008: 747). By dissecting two case studies, social representations of diabetes in Mexico and ethnic minorities in transplant medicine in the UK, we analyse how science, considered in its broadest sense (as it is practised and communicated), reinvents race and ethnicity and can inadvertently contribute to deepening racialised inequalities in stratified societies. We examine how this over-emphasis on ethno-racial genetic aetiologies in chronic diseases diverts attention and resources from more important influences on populations' health, such as embedded health inequalities exacerbated by colonial pasts, neoliberal capitalism and institutionalised racism. In line with recent discussions in the anthropology of epigenetics (Lock 2013; Thayer and Non 2015), we draw on Kuzawa and Sweet's work to suggest how 'social influences can become embodied, having durable and even transgenerational influences' (2009: 2). Ethno-racial differences in disease patterns are then embedded in pathways of power, characterised by a somatisation of racial tensions (Guthman 2014) that profoundly affects local biologies (Lock and Nguyen 2010). We argue that CE permits us to move some of these discussions forward in specific ways: for instance, identifying how biologies are moulded within their larger ecological contexts, or webs of relationships, and how social systems, ways of life and health are inextricably linked.

#### Ethno-racial discourses and health

Concepts of race and ethnicity are among the most controversial and contentious classifications in our social and scientific landscapes. In health research, genotypes have often been associated with ethnic/cultural identity, showing poor consistency in terminology and reinforcing ethno-racial stereotypes (Sheldon and Parker 1992). Race and ethnicity have then become mere statistical categories, denying the complex interactions among political-economic processes, lived experiences, societal ways of living and human biologies (Goodman 2000; Krieger 2001).

In this chapter, rather than engaging with race as a physical or phenotypical category, we draw on Gilroy's and Ahmad's understandings of racialisation. The former talks about it as the existence and hegemony of 'raciological' thinking that affects the world and provides differential access to resources for members of different groups (Gilroy 2005: 39), while the latter conceptualises it as a process that 'assumes that "race" is the primary, natural, and neutral means of categorization, and that the groups are distinct also in behavioural characteristics, which result from their race' (Ahmad 1993: 18).

We argue that race and ethnicity are polysemic terms, acquiring a plurality of meanings according to the (inter)national and local circumstances in which they are employed. Moreover, their use responds to ideological and political propositions grounded in power unbalances. The rise of the race concept in the fifteenth century as part of the European conquest and as a means of legitimisation (Smedley 1998; Ahmad and Bradby 2007) reveals its political and colonial genesis. Historically, the involvement of health within racial representations has been instrumental, not incidental (Keval 2016). Arguments on health and hygiene were (and still are) racially coded and have been central to (post-)colonial practices of inclusion and exclusion (Mawani 2003; Shah 2001; Gilman 1988). Nineteenth-century health and hygiene movements were concerned with maintaining the boundaries between populations.1

In tandem with biological depictions of race, ethno-racial differences in health have also been explained in terms of cultural inadequacies, mobilising essentialised notions of 'culture' (Ahmad 1993). According to Menéndez (2001), since the 1950s, we have witnessed an expansion of biological understandings of everyday life and the rise of the concept of lifestyle as a signifier for (un)healthy behaviour, working as a mechanism of differentiation, stigmatisation and subalternisation. Likewise, in health research, racial and ethnic-group comparisons of health indices frequently are presented without stratifying or adjusting for socio-economic conditions that could affect the interpretation of the data (Lillie-Blanton and Laveist 1996).

CE provides a criticism of dominant biomedical and epidemiological explanations of health and illness, unveiling their reductive biological orientation and shedding light on how large-scale political economic processes 'get under the skin' (Leatherman and Goodman 2011): for instance, how racism and chronic stress affect local biologies through processes of somatisation (Kuzawa and Sweet 2009) or how the evergrowing reproduction of capital under market rules reduces the spaces 'for the fulfilment of life and health' (Breilh 2008: 747).

#### Amerindian genes and the Mexican susceptibility to diabetes

Diabetes in Mexico has become a top health, social and economic concern. Its prevalence rate ranges between 9.2 and 14 per cent, making it one of the highest worldwide (world prevalence in 2014 was 8.5 per cent of adults aged 18 and older (WHO 2016)) and the highest among Organisation for Economic Cooperation and Development (OECD) member countries (OECD 2015). In only 30 years (1980–2010) diabetes has gone from being the ninth to the second cause of death in the Mexican general population (Secretaría de Salud 2012: 38). People with diabetes often have to endure suffering and pain due to severe disability. According to a recent report (Secretaría de Salud 2015: 20), in 2013, 30 million disability-adjusted life years were lost, especially among two age groups, adults between 35 and 60 years of age and the over-80s. The statistics are indisputable. What is questionable is how this epidemiological panorama is portrayed and addressed by a number of institutional actors, from state representatives and public health workers to researchers and journalists.

State representatives say the diabetes epidemic is a national threat. The Mexican ex-Minister of Health, Mercedes Juan, described diabetes as a 'health emergency […] capable of jeopardising [Mexico's] viability as a nation' (Secretaría de Salud 2013: 7). In 2013, President Peña Nieto launched the National Strategy for the Prevention and Control of Overweight, Obesity and Diabetes, designed to promote behavioural changes, increase epidemiological surveillance, make health services more accessible and regulate the sale of high-calorie food and beverage products. The strategy, contained in a 105-page document, showed a limited understanding of the role that social inequalities play in disease distribution. While launching his national strategy, President Peña expressed the need for citizens to be 'informed, active and healthy' and lamented the fact that the Mexican population 'suffers from overweight problems and lacks healthy habits'. He exhorted people to interrupt their sitting time with at least one hour of exercise per day (Presidencia de la República 2013). Discourses like these tend to frame diabetes not only as a Mexican problem but also as one that reflects *Mexicanness*, constructed around stereotypes of laziness, a propensity to over-eat and focus on the present, and the lack of a culture of prevention. In conjunction with behavioural/cultural explanations, the diabetes epidemic is also narrated in terms of ethno-racial predisposition, due to genetic variations that are 'exclusive of *mestizo* populations, whose *Amerindian* component is under study' (Secretaría de Salud 2013: 77; our emphasis). Although no national diabetes indicators by 'race' and/or ethnicity are available,2 Mexico has taken a leading role in genomic research, searching for 'a genomic haplotype commonly found in Mexican and other Latin American *mestizo* populations and linked to *indigenous genetic ancestry*' (Saldaña-Tejeda and Wade 2018: 2733; our emphasis).

This scientific endeavour has spurred public interest and widespread media coverage, particularly after the foundation of the Instituto Nacional de Medicina Genómica (INMEGEN) in 2004 and the start of the Mexican Populations Genomic Diversity Project in 2005. In 2008, scientists at the National Autonomous University of Mexico (UNAM) inaugurated the Genoteca Indígena, a project that aims to form a DNA bank from Mexican native populations. The objective is to know more about frequent diseases in Mexico, particularly diabetes, 'from their origin' (El Informador 2012). The investigation aims to detect the genetic polymorphisms associated with diabetes, which are said to be more frequent among indigenous peoples and, consequently, in Mexicans, depicted as a mestizo population with a high percentage of indigenous genetic ancestry (El Informador 2012).

Interviews and reports on the Genoteca Indígena released in Mexican media indicate that researchers give credit to James Neel's thrifty gene hypothesis,3 although it remains unexplained in what ways Mexican indigenous peoples might have had a more nomadic life in the past than other populations. The biochemist leading the Genoteca Indígena project argues: 'In the past, more than 6,000 years ago, when communities were nomadic, Mexican genetics allowed [Mexicans] to survive. This genetic make-up is today fattening them and making sugars harmful' (Menjívar Iraheta 2009).

Even though Neel's thrifty genotype is still an unproven hypothesis, its explanatory power has been astonishingly great (Fee 2006: 2990), as it provides an appealing answer to the high prevalence of diabetes and obesity among disparate ethnic groups, from the Pima of Arizona and the Oji-Cree of Ontario (Hegele et al. 1999) to Samoans (Minster et al. 2016) and Mexicans. Montoya (2011) underscores the fact that Neel's hypothesis remains elusive in at least two ways: the hypothesis rests upon disputable assertions about feast and famine cycles among populations, and the population groups deemed diabetes-prone are not biological but social groups (2011: 48). Thus, both minority groups and large national populations (but ones with strong links with indigeneity) end up lumped together because they share genetic 'ancestry'. In this regard, Ferreira and Lang ask: 'How can a genetic cause be applied across the borders of 300 million people divided into thousands of ethnic groups, living across the planet under strikingly different circumstances? What do these people have in common? Their genes?' (2006: 12).

Montoya (2011) suggests that the targeting of certain bodies as suitable DNA donors for research is made possible by the colonial practices that differentiated those bodies from the dominant ones in the first place, and confined them into poor neighbourhoods, plagued by poverty, neglect and therefore an excessive burden of disease. In the case of Mexico, it becomes clear that the reasoning by which (a) Mexicans are mestizos, (b) their indigenous genetic component is troublesome and (c) contemporary indigenous people should be targeted for DNA sampling is the direct result of Mexico's (post-)colonial history, which created the entire concept of the *indio* (Bonfil Batalla 1972), used it to place *indios* ('Indians') at the bottom of society, and pushed them into regions of refuge (Aguirre Beltrán 1967).

As several scholars have argued, *mestizaje* heralded 'the mixing of races rather than the separation of them, but without questioning the privilege of whiteness' (Saldívar 2014: 94). The proposition 'the whiter, the better' has structured Mexican racism, which works through 'distributed intensities' (Moreno Figueroa 2010) of white capital. The proposition 'the whiter, the less predisposed to diabetes', which seems implicit in the current scientific search for ancestral genetic backgrounds, sounds like the contemporary rendering of the Mexican *mestizaje* ideology. Indeed, the genomic enterprise – albeit not purposefully – articulates and is infused with racialised meanings that reflect cultural understandings of nationhood and alterity. As Wade et al. have pointed out:

Racialized categories are implied in the use of concepts of genetic ancestry – usually talked of in terms of African, European, and Amerindian components. For the geneticists, genetic ancestry (understood as very specific sets of genetic markers) is distinct from race (which they understood as a set of coherent biologicalbodily types). But the constant reference to African, European, and Amerindian ancestries evokes familiar racial meanings.

(Wade et al. 2014: 497–8)

The Genoteca Indígena substantiates the idea of Mexicans as *mestizos* with a double genetic inheritance (the black component is largely overlooked) and of native peoples as the authentic, 'original' key to Mexican biology. Consistent with this perspective, Mexican media explain the Genoteca Indígena project in the following way: 'Indigenous genes: solution to diabetes' (Ocampo 2013). The article details how:

Specialists agree that apart from promoting dietary and hygienic measures in the population, *the only way* to know *the origin*, complications and therapeutic management of diabetes, and to develop diagnostic, prognostic and control methodologies, *is to identify its hereditary components*.

(Ocampo 2013; our emphasis)

In order to identify those hereditary components, researchers extract DNA from indigenous groups, the more 'isolated' the better. The logic is that isolated groups, being genetically more homogeneous, make for a good case study. One study on diabetes susceptibility, for example, found an association of genetic polymorphisms with the development of type 2 diabetes in Mayas (Lara-Riegos et al. 2015). Researchers selected participants who 'confirmed a Maya origin, with parents and grandparents born in the same communities, speak their native language and preserve traditional folks' (Lara-Riegos et al. 2015: 69).

It is interesting to note that cultural and ethnic qualities were used as indicators of genetic ancestry. The choice of taking DNA from this ethnic group was justified on the grounds that Mayas are said to have little contribution of continental ancestry (Silva-Zolezzi et al. 2009, cited in Lara-Riegos et al. 2015: 69) and that the region they live in presents a high prevalence of diabetes. The blood samples were later genotyped to confirm Amerindian ancestry. The search for 'isolated' groups recalls ideas of 'purity', which anthropological and ethno-historical scholarship has often demonstrated to be at best imprecise and, at worst, pernicious (Kuper 1988). Thus the isolation of the Mayas of south-east Mexico appears at odds with past and present history. The historical record, for example, demonstrates intense black–Maya relations in Yucatán (Lutz and Restall 2005: 189). Although mixing was much more common in urban than in rural areas, by the eighteenth century (often informal) miscegenation had become commonplace in Yucatán, especially 'between enslaved African men and native or mixed-race women and, to a lesser extent, between female slaves and Spaniards' (Lutz and Restall 2005: 193). Although the study mentions the importance of considering local environmental factors, lifestyles and modes of subsistence (Lara-Riegos et al. 2015: 73), virtually nothing is said about this region's social history and the processes of adaptation to changing political and environmental circumstances. Indigeneity appears, once more, as a biocultural unity (with specific genetic and linguistic/cultural markers) but socially and historically decontextualised.

Questions remain about how these ethno-racial representations of morbidity and alterity are appropriated by dominant and non-dominant sectors of society, and how indigenous peoples themselves make sense of diabetes as the institutions of science scrutinise their bodies.

In her ethnographic experience with Oaxacans from Santa Maria Atzompa, Everett (2011) found that the genetic aetiological accounts circulating in Mexico had not made inroads at the household level and genetic susceptibility was not part of the explanatory models of people with diabetes. A similar finding comes from Laura's ethnographic research among an ethnic minority in southern Oaxaca. During her year of fieldwork, nobody ever mentioned genetic susceptibility as depending on their ethnic belonging. When they were asked why they thought they got diabetes, they usually referred to strong emotions related to stressful life circumstances. Diabetes narratives revealed stories of poverty, unemployment, classism and physical and emotional abuse, phenomena that thrive in contexts where structural violence silently permeates social relations.

Cristina, a woman in her fifties, had been diagnosed with diabetes 18 years earlier. One year before Laura met her, she had started experiencing diabetes complications and had had a toe amputated. When asked why she got diabetes, she said: 'I got diabetes from a *susto* [fright], a *coraje* [anger] I had when I was young. My father was a prominent political figure and they killed him. I was only 25, the oldest among my siblings and I had to take care of them. That's how I got diabetes.'  Moreover, diabetes affected her financially as she resorted to private medical doctors and expensive medications.

Pancho, a teacher living with diabetes for more than 15 years, was emaciated, unable to stand and on dialysis when Laura met him. He explained that his diabetes was due to a terrible *susto* he had in Mexico City when he took part in a street protest with his fellow teachers: 'I was part of the struggle of the teachers' union and during the protest we were attacked by riot policemen. They trampled on my *compañeros* and when I saw them falling I got terribly scared.' He reacted so strongly to the violence he witnessed at the hands of the Mexican police, he said, that his blood turned sweet.

When research participants were asked about the great numbers of diabetics in their community, they talked about environmental and dietary change, culture loss and social disruption (Montesi 2017). Of the 38 people in Laura's sample, only four, all males (between 39 and 52 years of age), literate and with a relatively high socio-economic position (two had been in the past high-ranking officials in the municipality, one was a teacher and one co-owned a pharmacy) mentioned heredity as a possible causative factor. In these cases, genetics was related to family history, not to ethnic belonging. When she purposefully inquired about genetic susceptibility to diabetes, people denied such a predisposition, as the words of Anita, 55 years old and diagnosed with diabetes 18 years earlier, demonstrate: 'I don't think it's a matter of race because at the time of my grandmother and of my great-grandparents nobody had diabetes. Today everyone has diabetes, including the young.' Most of the people with diabetes Laura worked with were first-generation diabetics, with vivid memories of healthy parents.

Aetiological accounts may change in the future as people with diabetes begin to have memories of disease in their own families and genetic explanations become more commonplace. Research into how younger generations understand diabetes aetiology and ethno-racial health outcomes is critical and urgent. As our opening anecdote with the tourist guide shows, the Mexican susceptibility hypothesis is already being appropriated by urban people with greater access to media. Moreover, the genetic link of Mexicans (and 'Latinos' or 'Hispanos' more broadly) to diabetes has also found coverage in the US, strengthening racist attitudes towards Mexicans, as this comment in a racist website demonstrates:

I have commented several times here re. the high cost of diabetes to a society. Diabetics' healthcare costs 2½ times the amount of nondiabetic healthcare. Diabetes is the cause of most blindness, amputations, kidney dialysis, & have 4x the chance of heart attack and stroke. A few years ago the *New York Times* had a week-long series of articles re. *Latinos' high rate of the disease. NYT claimed that 50% of them have it or will develop it!* And they brought up the issue of their diets, and lack of exercise. I also heard top US health officials express their concern over the coming diabetes epidemic *as we become a more Hispanic nation – and where the \$\$\$\$\$\$\$\$ is going to come from?*

(SentryattheGate, comment on American Renaissance website, our emphasis)

In the current climate of white supremacism and rising numbers of hate crimes, it becomes imperative to look at the potentially stigmatising effects that racialising scientific narratives have on ethnic minorities.

### Ethno-racial transplant medicine in the UK

Worldwide, increasing numbers of patients are affected by chronic kidney disease (CKD) and end-stage renal disease (ESRD), and are putting a substantial burden on global healthcare resources. This is due to the growing numbers of elderly people and the global pandemic of type 2 diabetes. In the UK, the annual incidence of ESRD has doubled over the past two decades to reach about 100 new patients per million of population (El Nahas and Bello 2005); this figure is expected to rise at an annual rate of 5–8 per cent (Lysaght 2002). 'Racial factors' have been described as playing a role in the susceptibility to CKD, as shown by the high prevalence of CKD related to hypertension, diabetes or both among BAME (black, Asian and minority ethnic) individuals in the UK (El Nahas and Bello 2005).

The National Institute for Health and Care Excellence (NICE) guidelines have identified higher-risk groups for diabetes, such as those aged 25–39 and of South Asian, Chinese, African-Caribbean or black African descent (NICE 2017). In a research review from 2002, the UK's Department of Health and the Medical Research Council attempted to address the rise of diabetes cases in minority communities, suggesting the implementation of innovative lifestyle changes, such as, for instance, working with Indian restaurants to provide low-fat alternatives on their menus (Department of Health 2002). Embedded in this health strategy lay the assumption that there was something 'faulty' within the minorities' diets which required a fix, reinforcing simplistic notions of minority culture and/or identity. This has also been promoted through the work of national network organisations such as Diabetes UK (Keval 2016).

Minority communities have been represented over the years as being at higher risk of getting diabetes and hence of experiencing related complications, such as kidney failure. The NHS website on organ donations and ethnicity states that patients from BAME communities are more likely to need an organ transplant than the rest of the population as they are more susceptible to illnesses such as diabetes and hypertension, which may result in organ failure and the need for a transplant. ESRD or chronic renal failure is permanent kidney failure (Gordon 2001; Sehgal 1999) and is treated by one of three forms of renal replacement therapy: haemodialysis (mainly done in hospitals), peritoneal dialysis (done usually at home) and kidney transplantation (Gordon 2001). Dialysis is the clinical purification of blood and thus it is a substitute for the normal function of the kidney. Dialysis is generally considered more expensive than kidney transplantation (Laupacis et al. 1996; Yen et al. 2004). In the foreword to a report on the Transplant Summit of 2006, the All-Party Parliamentary Kidney Group in the UK states that: 'Transplantation is better for the patient. Furthermore, transplantation is cheaper than dialysis. Increasing transplantation rates would therefore be an all-round win' (All-Party Parliamentary Kidney Group 2006: 3).

This demonstrates how transplantation is depicted by modern biomedicine as the optimum treatment for end-of-stage kidney failure and as the cheapest option for healthcare systems. This solution to renal failure is represented as the best option not only for patients in terms of their quality of life but also for the rest of society in terms of expenditure on healthcare. However, despite this call for increasing the number of transplants, there is a shortage of organs, from living or cadaveric donors, across different countries. The 2006 Transplant Summit report also mentions that the UK currently has one of the lowest donation and transplantation rates amongst European countries. They continue by saying that this is considered to be partly because of differences in health service capacity and structure: for instance, the report cites Spain as an example, describing it as having almost three times as many intensive care unit beds (from where donor organs are often retrieved) compared to the UK. In addition, the report lists 'procedural and attitudinal short-comings' as possible reasons for the low rate of donations. The text continues by adding that:

Innovative solutions must be found to maximise the opportunities for donation within the UK so that we can bridge the gap between accelerating demand and the declining supply of suitable organs available for transplantation. A national campaign should be launched to encourage potential donors to join the organ donor register. This should make clear to potential donors what the consequence of low donation rates are; not only for those individuals in need of an organ, but for the NHS as a whole.

(All-Party Parliamentary Kidney Group 2006: 7)

As a consequence, a public campaign to increase donations in the UK has been developed in the last decade. In the case of kidney transplantation, the campaign aims particularly to raise the number of living donations. It is common to find news aimed at increasing donations in the media. For instance, on 20 December 2016, the London *Evening Standard* published an article titled 'Metropolitan police officer gives Christmas gift of life to sister by donating a kidney'. Interestingly, this is the story of two white siblings. The transplantation happened in a hospital in affluent Hampstead (north London). The article ends with a comment by one of the consultants, saying, 'If you know someone who needs an organ I would urge you to think about being a donor'. Readers then are redirected to the NHS website for further information.

Similarly, the charity Give a Kidney promotes non-directed (also known as altruistic) donation in the UK. More than 100 people donated in this way in the UK in both 2013/14 and 2014/15, and the numbers are expected to keep on track at more than 100 per year. Research on non-directed living kidney donations has shown that the anonymity of the donor and recipient appears to be seen as a benefit, freeing recipients from the obligations of the gift (Bailey et al. 2016).

However, medical anthropology research in Spain (Sánchez Hövel 2014) has shown that public campaigns describe living donations as 'altruistic' and 'supportive/caring', not taking into consideration the long-term holistic wellbeing of living donors and the regret of having donated a kidney on the part of living donors when their health deteriorates later in life. Further research is therefore needed to establish the long-term consequences of living donations for living donors.

Undoubtedly, linking donation with gift-giving, altruism and self-sacrifice creates a 'medical duty obligating both individuals and collectivities' (Kierans and Cooper 2013: 222) to act as donors. Research has shown that possible organ donors have different degrees of duty according to the racial and/or ethnic categories they are thought to belong to (Avera 2009; Gordon 2002; Kierans and Cooper 2011). This classificatory system is based on the assumption that some genetically inherited human leukocyte antigen (HLA) types as well as blood groups appear in certain 'ethnic' populations more commonly than others, meaning that patients may be more likely to find a transplant match with someone in the same 'ethnic' group (Avera 2009). Therefore, individuals and collectivities thought to belong to certain ethnic or racial categories receive greater attention in terms of health campaigns aimed at increasing organ donation. This is the case of ethnic minorities in the UK, which are often urged to discuss organ donation (Siddique and Morris 2016).

For instance, in September 2017 the NHS had a specific website on organ donations and ethnicity that described BAME groups as 'more likely to develop medical conditions that need blood, organs or tissue donations'. The website also mentioned that 'people needing bone marrow are more likely to find a match with someone with a similar ethnic background', crudely implying that genetics equates to 'ethnicity' and 'race'. This has slightly changed today, with 'More donors from black, Asian and minority ethnic groups are urgently needed to address an increase in patients from the same communities dying whilst waiting for an organ transplant'.

As highlighted by previous medical anthropological research (Gordon 2002; Kierans and Cooper 2011), biological differences have been combined with race and ethnicity in this context, emphasising the largely arbitrary character of racial categorisations based on shared characteristics, such as, for example, skin colour ('black', 'white') or geographic location ('Asian'). Moreover, 'white' HLA types are constructed as the standard against 'rare' 'black' HLA types, failing to account for racial mixing and mixed heritage (Kierans and Cooper 2011).

There is also the failure to acknowledge that developments in immunosuppressants make HLA (mis)matches increasingly irrelevant (Gordon 2002: 136). Cohen (2001) writes about how transplantation rapidly went global with the development, production and marketing of the immunosuppressant drug cyclosporine by the Swiss pharmaceutical corporation Sandoz. This made transplants possible from a far larger group of potential organ donors than before, profoundly affecting the harvesting of organs and transforming the productivity of transplant clinics and their organ-donation targets. Research on pharmaceuticals shows how the macro level of the pharmaceutical industry and healthcare systems and the micro level of doctor–patient relations are interconnected (Britten 2008), affecting the expansion of pharmaceutical markets (Busfield 2010) and providing a quick and easy solution to the complex issues emerging when facing inequalities in access to transplantation and transplant listing. Kierans and Cooper write that:

In its attempts to accommodate 'rare' HLA types, transplant medicine has fallen back on the same classificatory schemas that were implicated in the creation of the inequalities that recent policy shifts were intended to address – schemas that are based, primarily, on the assumption of a 'natural' basis for cultural differences.

(Kierans and Cooper 2011: 13)

Therefore, 'ethnicity' and 'race' become biopolitical constructions in transplant medicine in the UK; these are often used to contrast the behaviour of ethnic minorities when it comes to donations in comparison to that of the 'white population', implying a higher moral stance for the latter. During an interview4 in a renal unit in the UK, an Asian patient – we will call him Sadiq – in his forties told Melania:

They [healthcare professionals] said to me that a lot of Asian people don't donate organs. My mum went through it and one of her kidneys was only 30 per cent efficient so they said no because she obviously was living on one; and my wife was not compatible and then after that I told the rest of the family not to go for it because I didn't want that responsibility. If it can happen to me it can happen to anybody in the family so I've just said I'd rather wait the time and wait for a donated dead one. […] Obviously, I got my brother and my sister, both of them went and had the tests done. I told them to go and have the tests done to make sure they don't have any possibility of kidney problems so that they are clear. I didn't want to take a kidney from any of those just in case. […] We spoke to a few people and again a few of my cousins came forward and said they would donate, but then again, the mental state I was in at the time. I refused to take it. […] I mean my cousin was only 20 at the time he offered as well; he was very fit, but I just said no. I'd rather wait it out and take it from someone that has already died rather than taking it form someone that is living; and if they get any complication it's just mentally you wouldn't … you would feel responsible for that.

The words of Sadiq mirror the attitudes and feelings of other renal patients Melania interviewed. Despite the difficulties of living on dialysis and their daily suffering and pain – which Yannis, a Greek man in his fifties, described as a form of disability – patients find it extremely difficult to follow healthcare professionals' advice to ask family members if they can act as living donors. This was also common among those who identified themselves as 'white'; of the 53 people in the sample, many noted that they would feel 'guilty' and 'to blame' if the donor became sick later in life, following the donation. 'I wouldn't want anyone to carry that burden, you know', commented Scott, a 69-year-old white British man.

Another important point is the fact that patients like Sadiq internalise what healthcare professionals communicate to them regarding ethnic minorities and donations; this certainly has important repercussions in terms of self-identity as well as in terms of perceptions of their own communities. As Nazroo et al. (2007) have shown, treating categories – such as Caribbean, black and South Asian – as universal needs to be problematised. This challenges the ideology of transplant medicine in the UK, which identifies people from different continents as the same only because they are defined as ethnic minorities in the UK. Moreover, within the same ethnic groups there are many differences, and mixed heritage in an increasingly globalised world is not considered. For instance, in terms of vulnerability to cardiovascular disease, there are similarities between white British and South Asian British people when talking about their health experiences (Lambert and Sevak 1996). This leads to the conclusion that using 'race' or 'ethnicity' to explain disease in a specific group is not robust enough.

Minority groups are constructed as dangerous to themselves and in opposition to the white majority; the 'problematisation' of minority health generates binary states of normal/pathological trajectories, with the latter associated with minority groups in the NHS in Britain (Keval 2016). As the UK government has, decade after decade, attempted to 'manage race relations' (Craig et al. 2012), there has been a corresponding effect on concepts of health and health services, with the notion of taking responsibility for one's own health becoming a prime focus for governments (Keval 2016) – for instance, through encouraging lifestyle changes.5

Therefore, in this context, minority communities are not only represented as being at higher risk of becoming diabetic, showing an evident ethno-racialisation of the disease, but solutions to diabetes' further complications, such as kidney transplantation, are also constructed as ethno-racial issues, as minority individuals are represented as unwilling to act as donors.

Hence, it is difficult to consider transplant medicine as a neutral biomedical technology (Ohnuki-Tierney et al. 1994), as it deeply affects and is also affected by cultural definitions of personhood and the dynamics of social relations within families, communities and countries. It tests different boundaries (Kierans 2011: 1469) as bodies become artefacts for social and political control, through increasing fragmentation and commodification within the context of biomedicine and economics (Scheper-Hughes and Lock 1987). Through these medical and governmental ethno-racial discourses, we can engage with constructions of sameness and alterity as transplant medicine provides a space to discuss what it means to be human, shedding light on the cultural and social constructions of the self and the other (Sharp 1995; Douglas 2003, 2004).

### Conclusions

The re-enchantment of scientists and lay people with genetic aetiologies and solutions to health problems is a social phenomenon that deserves full attention. It is important to recognise, though, that this is often an ambivalent re-enchantment (Bliss 2012). The cases of Mexico and the UK demonstrate the vitality of race and ethnicity as categories that shape biomedical and popular understandings of health and illness and, therefore, have an impact on how public health interventions are imagined. Transplant medicine and genetic modification (although not currently available) stand out as techno-fixes that operate at the individual level and simultaneously suit private interests. This has the inevitable consequence of shifting responsibilities for illnesses and conditions from the structural to the individual, yet they are marked by race and ethnicity. In Mexico, which is one of the largest consumers of sodas, the Coca-Cola Foundation has developed an interest in the genetic causes of diabetes: it is financially contributing to the Genoteca Indígena (Facultad de Química 2007). The suspicion is that the biggest producer of sugary drinks in the world has an interest in blaming faulty genes for the obesity and diabetes epidemic.

Epidemiology maps diseases along lines of race/ethnicity, gender or social class, providing a picture of a population's state of health. Its results can be used either to reinforce existing social hierarchies through racialised discourses of genetic predisposition compounded by unhealthy lifestyles or to explore social inequalities. CE offers theoretical tools to read ethnic and racial differences in this latter light, as the result of social histories marked by oppressive relationships that have an enduring, intergenerational impact on local biologies.

Breilh (2010) contends that the biological is always endowed with historicity; this means that physical, chemical and biological phenomena, as well as phenotypes and genotypes, are historically conditioned and cannot be isolated, fractioned or studied separately from their structuring social processes. Moreover, he adds, the connection between the biological and the social is not an extrinsic one but exists by virtue of subsumption (*subsunción*) (2010: 16). What are the implications of this theoretical standpoint?

A CE approach does not deny ethno-racial differences in disease patterns but sees them as incarnate results of pathways of power. This leads to novel conceptualisations of 'race'. For example, Guthman has explored non-genomic ways of thinking about 'race' and biology, suggesting that social constructions of race not only have material effects on social lives but can somatise 'race' (2014: 1156). Likewise, the concept of local biologies (Lock and Nguyen 2010) stresses the continuous, multi-level interactions among bodies within their life webs (Kuzawa and Sweet 2009).

Another relevant point of CE is the shift of gaze from 'health' to 'life'. Its object of inquiry is life itself, conceptualised as the sustaining web where everything happens or ceases to happen. This means that no aspect of our biology can be understood without taking into consideration its embeddedness in a complex ecology of mutually constitutive inter-relationships. Breilh criticises monocausal and multicausal explanations of disease because they favour proximate determinants of health over society-level ones. This critical posture has a practical, applied and political implication: if health has an intrinsic 'collective' nature, solutions to health crises have to be collective, too. Under this light, genes cannot be faulty, lifestyles cannot be bad and solutions can be technical only as a temporal relief. CE offers cues on how to overcome 'the epidemiological notion of the social as an inductive construction from the individual' (Breilh 2010: 17). A CE approach, therefore, does not analyse patterns of health and disease as the sum of individual risky behaviours or genetic make-ups but as the outcome of structures of power at work. It is social relations that empower or constrain people in and beyond their biologies. So what can a CE approach tell us about the appalling prevalence and incidence rates at which indigenous peoples and ethnic minorities worldwide experience diabetes or renal failure?

Ethnographic work on indigenous peoples with diabetes shows that diabetes sufferers link their illness to wider circumstances involving family and community disruption as well as social and environmental violence. The study of the narratives of people with diabetes reveals what a strong contribution ethnography can bring to health studies and why a mere account of lifestyles cannot be regarded as sufficient to stem diabetes. For instance, the seriousness with which anthropologists have approached and listened to life histories has led them to acknowledge the emotional dimension of experiences of vulnerability (see Jacobo and Orr, this volume), and the synergistic interactions between violence, suffering and diabetes (see Weaver and Mendenhall 2014, for instance). Biomedical studies have proved that 'chronic stressor exposure (such as living in poverty) has a health impact that goes beyond the supposedly bad behaviour of some people' (Kelly and Ismail 2015: 457).

Similarly, research on renal failure and transplantation can illuminate how ethno-racial difference and sameness are constructed, represented and internalised by different social actors. The communicative process is highly dependent on and structured by inequalities of power and resources; the organ shortage implies an assumption that organs go to waste if not donated, so every citizen should contribute to the transplant enterprise (Lock and Nguyen 2010). Normative theorists, clinicians and policy makers likely expect that patients make treatment decisions that enhance their health (Gordon 2001). Patients, however, make decisions according to non-normative factors, including their emotional and social notions about the repercussions of organ donation on a donor and on the patient's relationship with the donor. There is therefore a need for a renewed focus on patients' self-identity to explore how their treatment choices are embedded in the many relationships within which they are implicated.

The moral economy of transplantation has largely been boosted because of the global epidemic of chronic diseases such as renal failure, hypertension and diabetes. However, substantive research indicates that chronic diseases are themselves 'pathologies of power' (Farmer 2004) and symptoms of gender, class and ethno-racial inequalities that become embodied and are passed down from generation to generation. In order to break with this intergenerational cycle of violence, radical societal transformations are needed. CE recognises the practical and ultimately political nature of the scientific enterprise since 'there is an interdependence between how we *look* to reality, how we *think* it and how we *act* in it' (Breilh 2010: 8). CE offers 'collective health' as a theoretical, methodological and applied tool that focuses on group processes as they generate specific ways of living and dying. The 'social' is not an external variable useful to understand patterns of disease in individuals and groups, but the very condition that enables 'patterns' to occur (Breilh 2013: 20). Under this paradigm, biogenetic reductionism has no *raison d'être* and its exclusion from epidemiology clears the way for alternative explorations of race and ethnicity, which include the biological down to the genes but address them through a *longue durée* approach that links embodiment with social history.

### Notes

### References

Brown, Wendy. 2015. *Undoing the Demos: Neoliberalism's Stealth Revolution*. New York: Zone Books.

Busfield, Joan. 2010. '"A Pill for Every Ill": Explaining the Expansion in Medicine Use', *Social Science and Medicine* 70 (6): 934–41.

Conrad, Peter. 1992. 'Medicalization and Social Control', *Annual Review of Sociology* 18:209–32.

Gordon, Elisa J. 2002. 'What "Race" Cannot Tell Us about Access to Kidney Transplantation', *Cambridge Quarterly of Healthcare Ethics* 11 (2):134–41.

# Part III Political economy and judicialisation

### 8 Consultation rooms annexed to pharmacies: The Mexican private, low-cost healthcare system

Rosa María Osorio Carranza

Recent years have witnessed the expansion in Mexico of a private healthcare system promoted by the pharmaceutical industry, whose healthcare infrastructure consists of consultation rooms adjacent to pharmacies. These have been spreading throughout the country in connection with various pharmaceutical chains, chain stores, self-service stores or independent pharmacies. This healthcare system has become known as 'consultation rooms annexed to pharmacies'. It is defined as 'consultation rooms that are adjacent to a pharmacy with a direct or indirect connection such as belonging to the same business group, being on the same property, sharing a commercial brand and where the pharmaceutical company can determine the operating procedures of a consultation room' (FUNSALUD 2014: 15).

This chapter considers some of the characteristics of the growing number of consultation rooms annexed to pharmacies (CRPs) where a general practitioner (GP) provides primary healthcare services. Since 2010, these healthcare services have grown substantially, giving rise to a private system that is parallel with and complementary to the public primary healthcare system.

Using available information about this private general practice system, I will show how its emergence can be framed within the context of public policies aimed towards the privatisation of healthcare services and the simultaneous retreat of the Mexican public health sector. Finally, I describe how some users evaluate this kind of service and their motivations for using it.

GP consultation rooms compete to provide medical care for certain primary-level health problems, with qualified physicians providing very low-cost (between 35 and 70 pesos1 ) or even free consultations. They have a wide and growing geographical distribution throughout the country, mainly in urban areas, so that users have the option of consulting a physician very close to their homes, with a relatively short waiting time, and without admission requirements; all these factors establish it as the private medical system for primary care level with the greatest economic, geographic and institutional accessibility for certain socio-economic groups and populations.

Pharmaceutical chains account for nearly 80 per cent of all consultation rooms. The most relevant are: Farmacias Similares, Farmacias del Ahorro, Farmacias Unión, Farmacias Guadalajara, Farmacias Benavides, Farmacias de Genéricos Intercambiables, Farmacias Dr Descuento, Farmacias Multigenéricos and Red Médica Yza. Some are associated with certain commercial brands such as FEMSA (Oxxo-Coca Cola); others are linked to self-service stores such as Walmart, Soriana and Waldos, as well as a number of independent pharmacies that have installed their own consultation rooms.

From the pharmaceutical industry's point of view, and judging by its rapid expansion,2 this system represents an excellent new business niche, attracting and generating real or potential clientele for the medications sold in the adjacent pharmacy. Not only does this model expand the market, but it also creates consumers (users/patients/clients); thereby the processes of medicalisation induces and increases the consumption of pharmaceuticals, a process known as pharmaceuticalisation:

Pharmaceuticalisation denotes the translation or transformation of human conditions, capabilities and capacities into opportunities for pharmaceutical intervention. These processes potentially extend far beyond the realms of the strictly medical or the medicalised (Conrad 2007) to encompass other non‐medical uses for lifestyle, augmentation or enhancement purposes (amongst 'healthy' people).

(Williams, Martin and Gabe 2011: 711)

These two processes – medicalisation and pharmaceuticalisation – inherently draw attention and resources to pharmaceutical interests. Medicalisation does so by allowing a growing variety and quantity of biological conditions and sociocultural behaviours to be incorporated into, recognised or even generated within the sphere of biomedicine (Conrad 2007). The pharmaceuticalisation process is focused on making prescription drugs – biomedicine's principal and hallmark therapeutic standard for treating medical conditions under professional medical authority – whether that is justified or not.

The entire range of positive and negative consequences, affecting the population's health at micro and macro levels, has not been completely identified and analysed; neither has the quality of care given in the CRP system been evaluated. It would be simplistic to attempt to reduce an analysis of this system to the pharmaceutical industry's business marketing (Torres Guerra and Gutiérrez 2009). There are other actors and interests to be considered within the CRP system, for example those of the users themselves, who undoubtedly have greater access to professional medical care when CRPs are available.

From the point of view of the medical profession, this system provides a significant number of jobs for doctors, and forms a source of employment even though their contracts expose them to precarious labour conditions. Most of them are practitioners who are at the beginning or end of their careers as health professionals. They are not part of the complex training circuit of medical specialisation and subspecialisation, nor are they part of the public or private healthcare system at secondary or tertiary levels of care.

For the Ministry of Health and other government agencies, the CRP system is challenging because it is a continually expanding private system that grows without any clearly defined role within the three levels of the public health system, nor is it regulated as a private medical practice. This lack of clarity exists despite the important role it currently plays in out-patient medical care; particularly in urban areas, and sometimes even in rural communities, it is one of few available services.

From the point of view of critical medical anthropology, the pharmaceutical industry's expansion of market pre-eminence and the conditions favouring the monopolistic consolidation of large pharmacy chains are issues that merit scrutiny. Policy decisions taken by the public health sector have been crucial to the exponential growth of this system. In light of these issues, I consider that it is critical to focus the analysis on the importance of the CRP system's medical, cultural and political-economic dimensions. Hence this study will attempt to consider different perspectives on this complex issue, as well as the view of the social actors involved (Singer and Baer 1995).

Several questions arise: for example, how have the dynamics of treatment processes for common ailments been transformed? How do these clinics fit in alongside public healthcare services at all three levels? How has increased access to health services and the overprescription of medicines impacted new processes of medicalisation or pharmaceuticalisation?

Based on these questions, I set out to explore the experiences of CRP users and to understand their opinions about their quality of care and the perceived advantages and disadvantages when they compare service at these sites to care to a primary health centre or private practice.

In other papers, I have analysed the systems of knowledge and practice that are adopted in relation to the health-seeking process (Osorio Carranza 2001, 2013, 2016). Different social groups can, in relation to their own socio-economic conditions, adequately, empirically and theoretically assess the social performance and practices that involve technical and ideological symbolic knowledge. This ability enables them to make their own decisions about which healthcare resources they should seek in their therapeutic process, as well as determine their choice among available services to which they have realistic access.

Those seeking medical care initially treat themselves at home or with basic care, at least for some non-serious conditions or follow-up of certain chronic conditions; but this treatment process may be rechannelled into the CRP network of private out-patient coverage, which provides patients with faster and more timely medical care. Such micro-social processes parallel macro-social structural trends, such as medicalisation and medication of health-disease-treatment processes: the expansion of the pharmaceutical industry, its economic gains in the drug market and its control of the medical labour market, as well as the consolidation of national or international monopolies (Conrad and Schneider 1980, 1992).

Based on these factors, I propose an overview of the conditions in which the CRP system arises and operates, enabling us to contextualise its impact. I will offer several lines of analysis that allow us to compare it with the public system at the primary level; in order to do so I shall present the opinions of a set of CRP users that explain the rationale for their choice and convey their experiences as clients.

Given the fertile terrain for research, in this paper I gathered information from different available sources. Insofar as this system of medical care is an 'alternative' or 'parallel' system, available data is scattered among and does not necessarily coincide between different sources. This data, consisting of fragmented information from different sources, reveals not only ignorance about how the CRP system is working, but also the lack of systematic information and, above all, the absence of regulation by corresponding governmental agencies. To date, few detailed studies consider this field of medical care in detail. These include FUNSALUD 2014; Díaz Portillo 2012; Pérez Cuevas et al. 2012; Leyva Piña and Pichardo Palacios 2012; Leyva-Flores et al. 1998; Wirtz et al. 2011; Hayden, 2007, 2008, 2013; Gutiérrez et al. 2012, Oláiz Fernández 2013. Additionally, a great deal of information is available through printed news, digital media and the companies' own websites. In general, it can be said that only scant information is available about the operation of the system of GP consultation rooms annexed to pharmacies.

### An approach to primary healthcare: Public and private health services

In this section I will present an overview of the public health system3 at the primary level, which provides care for basic health issues that can also be addressed through out-patient services; these issues are also the most sought-for services by users of the pharmacy-dependent consultation rooms. The goal is to have a reference for identifying and comparing the growing importance of the private CRP system versus the public primary healthcare system throughout the country.

Despite a prior trend (since the 1970s) towards universal healthcare coverage (through various social security institutions or programmes implemented by the Ministry of Health directed towards rural or impoverished populations), because certain conditions are requisites for eligibility, the goal of universal coverage has not been met.

Data from the National Health and Nutrition Survey (Gutiérrez et al. 2012: 35) reports that over 24 million (21.4 per cent of the national population, estimated at 115 million) Mexicans do not have healthcare coverage or insurance. The official data for 2015 report coverage of 98 per cent of the national population, estimated at 120 million Mexicans (DENUE-INEGI 2017). However, it is worth mentioning that coverage statistics refer here to the condition of having a right to some kind of social security scheme and do not necessarily reflect the real access of the population to public health services.

According to the national data provided by the National Survey (Gutiérrez et al. 2012), on out-patient care services (over the 15 days prior to the survey), 61.1 per cent of the total number of consultations took place in public sector healthcare services, compared to 38.9 per cent in the private sector. Of those occurring in the private sector, the survey reveals that independent medical offices account for 58.5 per cent of private out-patient consultations, while pharmacy-dependent consultation rooms provide 41.5 per cent of the total.

On their own, pharmacy-dependent consultation rooms treat 16.1 per cent of total out-patient visits, reinforcing the importance of taking this sub-group into account. This breakdown of the private sector was not investigated in the 2006 survey, hence it is not possible to assess the changes over this period of time (Gutiérrez et al. 2012: 44).

In terms of infrastructure, according to the 2012 data provided by the Ministry of Health there are 71,767 public clinics, of which 29,208 medical units (40.7 per cent) corresponded to state or federal social security institutions, while 42,559 out-patient clinics (59.3 per cent) were accessible to the non-beneficiary population. The Ministry of Health oversaw 51 per cent of clinics, followed by the Mexican Institute of Social Security (IMSS) with 26 per cent of clinics, the Social Security Institute for Federal Workers (ISSSTE) with 8.8 per cent of the primary-level medical units, and finally, Petroleos Mexicanos workers (PEMEX), the Defence Ministry (SEDENA) and Marine Ministry (SEMAR) together constituted 4 per cent (Secretaría de Salud 2013). Notably, the Federal Commission for the Protection of Health Risks (COFEPRIS) identified approximately 10,000 consultation rooms attached to pharmacies for the same year, 2012, signifying that about 12 per cent of the national total number of sites providing care would correspond to the CRP system. The most recent figures would approximate a total of 16,000 CRPs in 2016 (COFEPRIS 2016).

These figures allow us to comprehend not only the scale of private care, but also its relationship with the public health sector. According to data from the National Health Survey, one-third of people affiliated to some type of public insurance reported using CRP, while two-thirds of the population without any coverage resorted to the private sector for out-patient consultation (Gutiérrez et al. 2012: 44).

The growth of CRP has skyrocketed since 2010: in only four years the number of establishments tripled; it is to be expected that the utilisation rates have correspondingly increased, similarly modifying the recourse to public out-patient health services. However, it is worth noticing that ENSANUT 2012 does not record the impact of the increase in medical consultations at CRPs, since its general conclusions about the use of out-patient services indicate that:

The use of health and out-patient services shows similar performance to that observed in 2000 and 2006 […] In terms of provision, public services as a whole represent more than 60% of total consultations, a percentage similar to the one observed in 2006. This means the pattern of utilization of out-patient services has not changed. It shows that about 3 out of 10 healthcare system users with public healthcare coverage opted for private care, a significant part of which occurred at pharmacies with out-patient care.

(Gutiérrez et al. 2012: 54)

In order to compare the total number of out-patient consultations provided by the public healthcare system to those of the CRP system, I used the number of general medical consultations offered in all the public health services as an index, close to 223.5 million out-patient consultations per year. According to COFEPRIS (2014), about 9.7 million consultations per month take place within the entire CRP system, or 117 million consultations per year. However, it should be emphasised that, given that no precise survey of the system's operation or enumeration of CRP facilities exists, the above figures are only estimates. These data reveal the growing importance of the private out-patient care system that would be equivalent to half of all medical consultations of the public primary care system.

The director of COFEPRIS recognised that 'the CRP system should be used to implement prevention programs and health policies; and the 32,000 doctors who attend these clinics can apply the same prevention and control measures used in public facilities' (Rodríguez 2014).

Critiques of this model are principally oriented at emphasising the inadequacies of the public healthcare system and its inability to respond to the growing demands of a population prone to acute and chronic diseases, requiring long-term care and continued use of pharmaceuticals.

Although the expansion of the CRP system means greater access to medical care, the encroachment of the private healthcare sector and the pharmaceutical industry, and concurrent influence on increased drug consumption and out-of-pocket patient expenditure, cannot be ignored.

### Public health policies: The driving force behind the CRP system

I start by considering that one of the principal functions of the state is to guarantee the right to health, and to increase effective and timely access to public health services in terms of equity, quality and accessibility, especially for the most disadvantaged sectors of the population. However, this function is affected when the supply of public services stagnates or is reduced relative to growing demand, while its services are replaced by contracting to private companies. In this sense, one can say that the expansion of the private system of primary care has been promoted and permitted by the state through certain public health policies. For practical purposes, this implies recognising the weakening or diminishing of the state supply of basic care services, opening the way for the pharmaceutical industry to provide this function.

One of the public policies that favoured such exponential growth of CRP had its origin in the August 2010 agreement issued by the Ministry of Health prohibiting the sale of antibiotics without a medical prescription, which had been a common practice in Mexico until the time. The official argument was that the inappropriate or excessive use of antibiotics generates a problem of bacterial resistance; it emphasised the risks of self-medication, attributing a large proportion of the deaths recorded during the AH1N1 influenza epidemic in Mexico in 2009 to poor selfadministration of antibiotics (COFEPRIS 2013):

The inappropriate use of antibiotics poses a risk to the health of individuals and increases the costs incurred by families and healthcare services. Additionally, it contributes to the growing epidemic of bacterial resistance, consequently creating the need for more expensive treatments and higher mortality from infectious diseases, for which reasons it is considered a serious global public health problem. In this context, antibiotics are considered a global public good [… t]he growing negative consequences of the indiscriminate use of antibiotics in our country [Mexico] reveals the need to take stricter regulatory action in the short term, such that patient safety is ensured and public health protected. These regulatory actions include restricting the sale of those antibiotics that are of critical importance as soon as possible, requiring that they be dispensed only by medical prescription.

#### (COFEPRIS 2010c)

According to data provided by COFEPRIS (2010a), this government decision led to a reduction in the sale of antibiotics (the second most sold drug in the country) of almost 14 per cent in the period from 2010 to 2012 – from approximately 61 million units sold in 2010 to 49 million in 2011 and almost 45 million in 2012.

As per this agreement, with the justification of not leaving the population unprotected and guaranteeing regulated antibiotics prescription, the public health sector modified its policy towards the pharmaceutical industry; beginning in 2010 it authorised the general establishment of this type of medical practice annexed to pharmacies.

In the same year, a wide variety of drugs that until then were classified as 'similar' were certified as 'generic': that is, they could be considered as pharmacological equivalents or chemically biocompatible with the respective patented drugs. This pharmacological equivalence was certified after five years of clinical trials. Thus, in 2010 drug classification decreased from three categories (patent, interchangeable generics and similar) to only two (patent and generic) (COFEPRIS 2010a). This reclassification boosted the mass production of generic drugs prescribed and distributed in CRPs that are associated with pharmaceutical laboratories, each producing generic medications under its own brand.

The detailed analysis by Hayden of the relationship between drug patents, trademarks and the increased production of generic drugs in different countries states that:

In Latin America, where my research is concentrated, generic drugs have become new and important features of national pharmaceutical landscapes […] and the category 'unbranded generics' is the fastest growing pharmaceutical niche in both Mexico and Brazil. […] We might make the simultaneously obvious and strange argument that the pharmaceutical market is becoming commodified; that is, it is being genericized and the commercial landscapes [are] saturated by sameness.

(Hayden 2013: 604)

Since the late 1990s, a part of the international pharmaceutical sector has reoriented its research and production towards interchangeable medicines. A sector of the industry is directed to the elaboration and commercialisation of drugs that are copies of the original, when the patent of the laboratory that designed them has passed into the public domain; these copies are called similar, generic, interchangeable generic or biosimilar, and are sold at a lower price than the patented originals.

However, there are different levels or kinds of sameness or similarity, depending on national public policies and specific norms and regulations that change across time and place. For example, the dominant criteria may be bioequivalence (similarity in the chemical substance) or bioavailability (similarity in the blood absorption rate of the active substance) when evaluating the active substance, its effectiveness, safety and time of action – notions that influence determinations of 'pharmaceutical equivalence' and 'interchangeability' (Hayden 2013: 606).

The generic market in Mexico has grown to 40 per cent of the total drug market. The proliferation of generics, aided by their low price, has helped to establish a new category of drugs and a growing consumer market. The most notable example is the market-leading Mexican pharmaceutical chain Farmacias Similares, whose advertising emphasises: 'The same but cheaper', 'We call ourselves Similar, we are generic'; or the case of Farmacias GI (Generic Interchangeable), whose advertising motto is '[We are] Your generic expert'. The same applies to other pharmaceutical chains who have launched their generic 'own brand', announcing only the generic chemical formula and distribution company on packaging: for example, generic GI; generic FarmAhorro (Farmacias del Ahorro); generic Medimart (Walmart); generic FABE (Farmacias Benavides). The circuit of production, distribution and marketing of generic drugs is therefore perfectly complemented by a physician's prescription from a CRP, and by their sale through partner pharmacies (Hayden 2007, 2008).

The two aforementioned Ministry of Health public policy decisions that coincided in 2010 would, together, spark the proliferation of this type of clinic and drugs throughout the country. The pharmaceutical industry's response was quick and definitive: consultation rooms were installed next to pharmacies and the production of cheap generic medicines marketed under the particular pharmaceutical brand increased.

Based on the COFEPRIS data, at the beginning of 2015, over half (53 per cent) of the 28,000 pharmacies in the country had a clinic. The regulatory organisation itself noted that as of 2010, the date of the aforementioned agreement, the number of CRPs quadrupled, from 4,370 to 16, 000. Over only five years (2010–16) they increased by 366 per cent (Table 8.1).

The accelerated growth is highlighted by the comparative sluggishness or absence of regulation by the public healthcare sector. Only in 2013 did the governing entity, COFEPRIS, propose the need to regulate and supervise these establishments, implementing guidelines for best

**Table 8.1** Growth of consultation rooms annexed to pharmacies in Mexico, 2010–164

*Source*: COFEPRIS data at: http://interactivo.eluniversal.com.mx/2018/mapaconsultorios-farmacias/mapa-consultorios.html (accessed 1 November 2019).

practice and penalties for breach of regulations, fines, and in extreme cases, temporary or permanent closure of the CRP (COFEPRIS 2013). Among the main regulations are the prohibition of direct communication between CRP and pharmacy, and the requirement that physicians have professional qualifications, with appropriate facilities for diagnosis, examination and maintaining clinical files.

This private healthcare system was gradually made operational by several pharmaceutical brands. By the end of June 2014, CRP distribution in pharmacy chains represented 62 per cent of the market. They were present in 16 per cent of self-service stores and 16 per cent of private pharmacies (Table 8.2).

It is useful to analyse the CRP healthcare system within the framework of public health policies: that is, by examining authorisations, regulations and government negotiations with the pharmaceutical industry, and through the work of regulatory agencies. By 2013, the director of COFEPRIS, Mikel Arriola Peñalosa – later appointed (in 2016) as director of the Mexican Institute of Social Security – gave the following perspective on this kind of connection between pharmacies and clinics:

This is good news for healthcare coverage because pharmacies have even more [market] penetration than banks; we are talking about almost 2.5 pharmacies per 10,000 inhabitants […] and for pharmacies and self-service chains, the outlook is even more favourable. An anticipated 90% of dispensed drugs will come from these two channels in 2014, of which 60% correspond to the [pharmaceutical] chains […] as a regulatory authority and in accordance with occurring economic and health phenomena, adapting to new areas of business is always a challenge for us, but we cannot lag behind anymore. (Arteaga 2013)

**Table 8.2** Number of CRPs in principal pharmaceutical chains, June 2015.

*Source*: *El Universal* newspaper, 4 September 2015, page B3.

Almost 15 years after the emergence of the first CRP, although the regulatory agency was already well aware of the importance of this phenomenon and its impact both on health coverage and on prescription drugs, only in 2013 was the necessity of adapting to these growing economic and health processes taken seriously, when regulatory best practices to control and supervise such establishments were put into effect. The public policy determined by the Health Ministry thus allowed and promoted the expansion of these offices throughout the country. However, it has since shirked its role through its failure to regulate and monitor their proper functioning.

Another aspect of this relapse of state governance regards the provision of health coverage to the population. For health issues considered 'non-serious', taking a balance of time, needs and results into account, people will usually go to a CRP or directly to the pharmacy near their home, instead of their affiliated public health centre or clinic. For this reason, the growing number of CRPs represents a diversification and expansion of access to primary healthcare for the entire population, and particularly for those sectors that do not have effective and timely access to public health services. In this sense, there is a general, indirect decrease in the demand for public health centres and clinics, not only for medical consultation but also for the free medication supplied through social security institutions and those dependent on the Ministry of Health.

The production, distribution and sale of generic medicines at low cost through the CRP system transfers public-sector expenses to users/ clients/patients, who buy them at the pharmacy next to the CRP, absorbing their cost, and increasing their out-of-pocket expenses.5 This decrease in the demand for public-sector consultations and drugs reduces public health spending and functions as a safety valve to relieve pressure from the need to expand public health coverage.

In this sense, it is important to understand and analyse healthcare policies and services systemically and relationally, being aware of their contradictions and complementarities, and identifying the connections and decision-making between the public and the private health sectors, in which there are different social actors with potentially different goals and challenges. For example: the government has determined public policies through the Ministry of Health and other public institutions; the pharmaceutical industry seeks to meet its economic interests and business objectives; medical professionals are aware of their labour needs. Above all, the population that requests and uses accessible health services makes specific choices from the available options based on a set of conditions and factors: they are users of specific services, patients who expect medical care from a practitioner who fits a certain profile; they are also clients: potential consumers of prescription drugs.

### User feedback: Why do they prefer consultation rooms attached to the pharmacies?

It is clear that an extensive and low-cost private healthcare system has been developed at the primary care level. This system complements the public out-patient system and, in a certain sense, displaces or at least competes with the traditional scheme of the private physician whose office is independent, but whose consultations are comparatively more expensive.

I interviewed users of three CRPs located in very close proximity to each other. They were asked about their opinions regarding the care received at these consultation rooms and how these compared with the public ambulatory care services and with other private GPs which they had attended. My research conducted short interviews in a middle-class neighbourhood in the south of Mexico City,6 where three consultation rooms annexed to the pharmaceutical chains Similares, Unión and Ahorro are located within 50 metres of one another, with a high number of users: neighbourhood residents, passers-by or local workers.

According to the observations of this study, at the Similares and Unión pharmacies medical care is available from 9 a.m. to 10 p.m. from Monday to Saturday, and from 10 a.m. to 5 p.m. on Sundays, with doctors attending in two shifts. Free medical advice was offered in Farmacias del Ahorro only from Monday to Saturday, from 9 a.m. to 7 p.m., with a pause for lunch. The influx of customers varies according to the day of the week, time of day and the attending professional. On weekends and some evenings there are more users in Farmacias Similares CRP, while during the week, the doctor who attends at the Unión pharmacy has gained the confidence of users and some report that this doctor is 'very experienced' and 'very effective'.

During this preliminary inquiry, I interviewed 10 women who had used the services of these CRPs at least once, asking questions about the condition for which they sought treatment, their experience in the type of care received and how this compared to other primary healthcare services, like that of the health centre and Mexican Institute of Social Security (IMSS) clinics.

Generally, the reasons for seeking treatment are mostly episodes of acute respiratory or gastrointestinal infections, although the patients also mentioned accidents, treatment and monitoring of chronic diseases such as diabetes and hypertension, and issuance of medical certificates:

So far this year [over a four-month period] I have been to Similares four times: to take a blood test [glucose], for the flu, for a medical certificate for my daughter, and I [went] with my eldest son [28 years old] to get vitamins because he was very thin; he asked me to accompany him. For the whole family [five members] I think we go about eight times a year; my husband almost never goes. I always go for minor issues. Now there are also some pharmacies with consultation rooms where you can also go for fractures, to have stitches removed or get [saline] solution. [You] can't [go] for more serious problems since they do not have enough medical equipment.7

I have gone to the Similares when there are minor issues and I have no one to accompany me. It is more practical, because I don't have to cross the city, [or] stand in line; it is an accessible service when it is nothing serious; it solves my problem. When more attention is required, then I go to the private doctor, which of course is much more expensive. I don't go to ISSSTE.8

This frequency of use can be compared to those who have social insurance but who end up only using the CRPs:

I usually go to the health centre, or social security. On Saturday, both are closed and so I went to the Farmacias Similares because there they treat flu and coughing, and as I felt as though I were choking. They gave me medicine that does not have the same name as the patent, but thank God, I recovered. About Farmacias Similares, my sons and my daughters-in-law go there a lot. They get blood work done there. My daughter-in-law fell and fractured her foot; they took X-rays and treated her foot right there. She also takes her three small children there. They go for a headache, or upset stomach.9

I once went to the ISSSTE for emergency [care] because it was a Sunday night. I was vomiting and had a stomach ache, but when I got to the emergency room, they told me that the doctor had gone to dinner. The only open service nearby was a Farmacia Similar that attended patients at night. I went there, but there were about 10 people ahead of me, children, adults; they looked bad. It took a while, but at least I was given something to ease the momentary discomfort.10

In general, the difference in frequency of use is determined principally by the socio-economic status of the user, as reflected in occupation and schooling, as well as their neighbourhood and access to social security or private medical insurance. It was expected that people in the most unfavourable conditions would report a greater use of the CRP system. Less obvious was that that even people from comparatively better socioeconomic conditions have also used them on occasions, or at least once. It is important to mention that in all cases users frequently used the CRP to buy generic drugs on account of their lower cost compared to patented medicines.

The interviewees recognise differential care among the major pharmaceutical chains, even when they have only used CRPs once or twice. There is a clear preference for Farmacias Similares,11 whose advertising campaign used the popular image of 'Dr Simi' (a caricature of an elderly, congenial cartoon doctor).

I think the [system of] pharmacies is beginning to grow. Around the year 2000, the first one was Similares. I go [to] the Similar more. I've been to the Farmacia del Ahorro only once in my life and that was last year. I had a very bad stomach ache but they didn't attend me, actually the doctor didn't see me. He was there [in the office] and came out and said, 'I will be back in a minute', but he left me there waiting for half an hour. I asked [for] him directly; but he didn't come out any more and I stayed there alone. After that I said, even though they do not charge for the consultation, what is the use if the doctor is not there; that is why I prefer to pay for the consultation in the Similares and they see me. It is the one I rely on the most and the one that has the most [branches].  (AC)

Dr Simi is closer and always open. The medicines are cheaper, almost half the cost of patent [drugs]. I do not find any deficiencies with the Farmacias Similares. I've been to Farmacias del Ahorro to buy the medicine about three times.

(AB)

In the Similares there are [good] doctors and there are [less able] doctors; but in the one I go to, medical care is good because [the practitioner] examines you, and prescribes medicine according to the diagnosis. Before they did not do that, previously they would just prescribe the medication. Now they prescribe the medicine for three days, for example, and say 'In three days please return for a check-up, to see how things are going.' If the medication they gave you was the right one, and you are already feeling better, you don't go back. If you [do] return on for your scheduled follow-up appointment, then you do not have to pay for the consultation. But if you return on another day, then you have to pay again. I think that the treatments are [just] ok, because sometimes they work and sometimes they don't.

(FT)

I come here (Unión) because the afternoon [attending] doctor is very good. I once came for a throat infection and he cured it very fast. You can see that he has a lot of experience and there are always people waiting for him. Now I came because of a backache.12

The interviewees also compared the care received at different primary care public and private facilities in relation to GPs at CRPs. The basic differences in types of service are: waiting time for consultation, out-ofpocket expenses, quality of care and available infrastructure.

I think Similar is better than the primary health centre because at Similar, it's your turn and that's all; there's one doctor who examines you calmly. At my health centre, the doctors have barely had [time for] their coffee, when they see so many people [already there] that they become disheartened and they [only] see patients as long as they want to.

(AC)

At the Similar, to exaggerate, it takes about two to three hours at most to get medical care when there are a lot of people; but at the health centre it is almost a full day. If I want to be among the first [in line], I have to arrive by 5 a.m. in order to the 24th or 30th turn. They begin to distribute the numbers at 8 a.m. and only distribute between 40 and 60. It is like in the IMSS; it is exactly the same, it takes all day. (TI)

The way the doctor attends at Similar is more practical; at the health centre, the nurses are mean, very rude; it goes back to the same thing, there are so many people that the attention is not good. For example, with the sugar-glucose test, they don't do the test [at its scheduled time]; [they] only say that it was [supposed to be] at 8 a.m., and at 9 a.m. they say [the test] can't be done any more. If we are fasting, what is the problem with doing it, even at noon? If you go there fasting, I say that they can do it.

(AB)

On the other hand, the main comparative disadvantages of the CRP are the professional qualifications of the doctors, the clinic's equipment and the quality of the medicines. With regard to the attending physicians, the main comparison is made with private doctors who have traditionally practised in their neighbourhoods:

I feel that there are differences between doctors. In the Similar, I feel that they, as they themselves say […] are rotating doctors. They are [still students] writing their theses, while [the doctors] at the health centre have already graduated; they already have their diplomas, their title.

The doctors at Similar are young people who have just finished studying; they have no experience, but they do attend well. The medicines are the same, but cheaper. I think the private doctors are best; but there, since you are paying, the consultation is better. It is very expensive, that is why I prefer the health centre, because with popular insurance, they do not charge me.

(AB)

(LU)

I think that to improve the Similares, they should have a better stock at the pharmacy, the most necessary that cannot be found elsewhere. The clinic could also have better more up to date equipment; Farmacias Similares gave us a glimpse of a private practice, where there are more things, more [medical] devices. It should be better equipped in order to be like a private physician's practice.

(TI)

The statements about the types of prescribed medications indicate that the population recognises a qualitative difference between patent drugs, generic drugs and those of the 'Similar' brand. Thus, the slogan 'The same, but cheaper' is not assumed to be entirely true, since these drugs are considered to be lower quality or to have less therapeutic efficacy. This evaluation is similar to the one made regarding private physicians, in which it seems that quality is directly proportional to the price paid for care:

You can buy the prescription in any Farmacia Similar; almost always the medicines are Similar brand. It cannot be patent [medication], because in the Similar there is no patent [medication] and vice versa, in the patent pharmacies there are no Similar brand drugs. The patent medicine is more concentrated. For example, when Amoxilina [sic] was prescribed to my daughter for an infection, the Similar brand came in a light pink colour, pale, more discoloured; the patent [medication] comes in strong pink, like strawberry. The Similar brand comes discoloured and the patent has more colour. In the health centre the generic medication is also a little weaker, but not as much as the Similar.

(AC)

Finally, I requested an overall assessment of the public health services used by interviewees in order to verify the positive and negative representations made about them. Complaints refer to the waiting time for consultations, the lack of organisation, the lack of warm and friendly staff and waiting lists, even when they recognise the out-of-pocket savings, both in consultation fees and medicine:

I have not been back to the health centre for years; because, though there is no charge for the consultation, it is always chaos there and better that I do not go. [Some] people use the health centre a lot because they have to go there to submit documentation to receive their government assistance in the Opportunities Programme. But since I don't have to do any of that, I do not go. They will see me [there] but give priority to those who are enrolled in the programme. I have *Seguro Popular* insurance, but that is only valid in hospitals; at least there, it does work. Or, for example, when my daughter had surgery for her appendicitis, I was seen under the *Seguro Popular* insurance.

(AC)

The testimonies note the factors that influence the choice of services, such as long waiting times, the consultation hours, mistreatment and inadequate facilities; all of these issues can dissuade users from seeking treatment in public health centres, although all recognise that care is free for those who have public insurance benefits.

Overall, choosing CRPs – mostly the Similares – is explained by the shorter waiting times, lower comparative costs and adequate relative efficacy for conditions considered not serious. Their disadvantages include less training for physicians; infrastructure limitations that prohibit attending for other major health problems; lower quality of generic drugs compared to patent medicines; and out-of-pocket expense.

In all cases, users acknowledge that better care would be offered by private doctors, private clinics or even private hospitals, because the doctors would be better prepared and better patent medicines would be prescribed. Of course, the obstacle to accessing them is the high cost of the consultation and of the medicines.

### Final considerations

Throughout this chapter, I have tried to describe and analyse how over 20 years a parallel system of out-patient medical care delivered through pharmaceutical companies has been built. This system complements or even replaces the public health system at a primary care level, thanks to ease of access to facilities, its low cost and broad geographical distribution. I have also emphasised how policies implemented by the public health sector have promoted and consolidated this private system; finally, I have explored the main reasons why these pharmacies have become so popular.

By means of conclusion, I will take a political economy perspective to understand the macro, meso and micro dimensions of this phenomenon and to identify stakeholders and interests in both the public and private arenas of the Mexican health system (Singer and Baer 1995). At the macro-social level, it is essential to consider the economic dimensions of the pharmaceutical sector and its impact on the national economy in terms of its contribution to gross domestic product. The industry of health and disease not only involves the production and manufacture of drugs, but also depends on a complex circuit involving the certification, marketing, distribution and sale of drugs, where the prescription constitutes a strategic link in the chain, and the CRP system becomes a privileged space for this purpose, especially if an over-prescription of the drug is supplied.

In the past decade some progress has been made in terms of extending healthcare coverage to populations that did not have any form of social security. Although it can be said that at present there is institutional coverage for a basic suite of diseases and medicines, serious deficiencies persist in terms of real and timely access to services, particularly for people living in conditions of poverty and extreme poverty. The emergence of a private health system accessed through economic and political power directly or indirectly corrects these shortcomings, even at the expense of transferring costs to the user and devaluing the professional knowledge of doctors.

The shortage of medicines, lack of material, financial and human resources, long waiting lists and disarticulation between the three levels of care should be questioned as part of a social health policy. Research must respond to this by identifying resources that provide analytical and collaborative instruments to generate a counter-hegemonic social response based on a greater awareness of the rights of the population to demand and secure their right to health. As for the state, a greater regulation of the CRP system would be desirable to take advantage of and promote, from this same private-sector platform, prevention and health promotion policies. From a critical anthropological approach, it is expected that the CRP system will continue to generate greater privatisation of services, the commodification of health and disease and a greater biomedical hegemony through the medicalisation and pharmaceutisalisation of social representations and medical practices.

The hegemony of biomedical knowledge manifests itself not only through the clinical encounter, the patient–physician relationship and biomedical prescription, but also in self-medication processes or the search for 'magic pills' that solve everyday problems, as widely discussed in the media (Menéndez 1983, 1990). Examining the articulations between the processes of medicalisation and pharmaceuticalisation exceeds the objectives of this paper, but nevertheless it can be said that these processes feed into and strengthen each other. With biomedical hegemony and the processes of medicalisation in our societies preponderantly focusing on the consumption of drugs, the prescription process itself has become a pillar of this hierarchy. However, the social responses of the population depend on multiple transactions between social actors. We have seen that their choices regarding the use of services are mediated by multiple conditions such as the type of medical condition, their socio-economic profile and the specific context within which the need for care is generated. Decisions involve a set of representations, practices and experiences associated with public and private health services (Osorio Carranza 2001).

The main advantages of CRPs are their relative therapeutic efficacy when treating certain health problems, geographical accessibility, the lack of enrolment requirements, minimum waiting times and reduced consultation costs. The disadvantages are the almost non-existent regulation and supervision by the relevant institutions, limited infrastructure, unstable working conditions and low medical qualifications, drug over-prescription and the paucity of information regarding the doctor–patient relationship and quality of care within these clinics.

This state of affairs is complemented by the negative popular evaluation of public healthcare services due to prolonged waiting times and poor quality of service, despite recognition of the benefit of free consultations and medications. Private practitioners – in the traditional sense – are identified as being better care providers and simultaneously the most expensive.

The large number of consultations taking place within the CRPs' clinical network seems to indicate that broad sectors of the vulnerable population, especially those without social security or the middle class, which need or would prefer a fully qualified physician, are reorienting their search for medical care towards these clinics. This system offers the possibility of medical care to disadvantaged sectors of Mexican society and is often the only possibility of professional medical care available to them. The new type of service offered by CRPs has become the second most important system of out-patient care at the national level, and is increasingly relevant to the health-seeking and treatment paths for different medical problems.

In this sense, it is worth pointing out that having a medical practice associated with a pharmacy is not a new phenomenon. Throughout the twentieth century, private medicine was expanded by GPs, who would install their practices in rural and urban areas and subsequently open their own pharmacy where their patients could purchase the medicines they prescribed. The private doctor's practice would append a pharmacy adjacent to it; here the medical professional was pre-eminent and the commercial function of medication sales passed into the background.

In the current context, this relationship has become reversed: the pharmacy will add a medical practice. Nowadays the large pharmaceutical chains that install and control CRPs are also the ones who hire the doctor to work for them.

Pharmaceutical industry operation displaces and imposes itself over the medical professional; the interweaving cogs between the pharmaceutical industry and the medical profession are highly sophisticated. By prescribing medicine in their practices, private doctors became principal distribution agents of retail drugs; realising this, pharmaceutical representatives would strive to influence private physicians to prescribe a particular drug. Now, through the installation of CRPs – along with the mass production of generic drugs – the pharmaceutical industry has managed to incorporate autonomous medical professionals among its employees; within its operational functions the pharmaceutical industry has managed to, literally and in a very specific way, put the medical profession entirely at its service, including ceding its autonomy. The role of the pharmaceutical industry as a healthcare services provider – beyond just providing medicine – is becoming fundamental, to the extent that the Mexican government and its public policies have focused on prioritising the economic dimensions of the CRP system above those of healthcare itself.

In this sense, it is significant that much of the information about the CRP system found in various printed or digital media gives commercial and business perspectives, as if this issue were purely entrepreneurial or transactional. This stands in contrast to the paucity of information available from the perspectives of healthcare systems or the consideration of medical and health outcomes.

Along the same line of analysis, it has been noted that in the results of the 2012 National Health Survey, the impact of this system was poorly recognised and the Ministry of Health is not generating systematic information about it. It is striking that it is easier to find statistical information under the category 'general practice doctors' offices in the private sector' in the Statistical Directory of Economic Units (DENUE-INEGI) than available Ministry of Health data about private out-patient health services.

However, the problem appears to lie not only in the expansion of this network of clinics and in its minimal regulation, but in the fact that, rather than being a supplementary alternative to health centres and public clinics, it has gradually become the most accessible option for certain sectors of the population. It could be a positive addition to existing public or private services that users could access without obstacles, one alternative among many that allow the public to access the healthcare service and medical professionals of their choice; such a situation now appears utopian.

As we have seen, public policies explain how and why this privatisation process is in line with the state's contraction and growing deficiencies in the public healthcare system. From this perspective, the main critique must be directed at the public healthcare sector and governmental institutions that should guarantee the right to health for the population and offer a real universal coverage scheme that, minimally, provides effective and timely access to primary care.

In Mexico's current political context, the federal government is promoting change to the national health system, which would include reforms to the Health Law, the gradual unification of social security services, the creation of a National Institute of Welfare (INSABI) that will replace the Popular Health Insurance and absorb the IMSS Welfare Programme (formerly IMSS-Prospera) and the health services of each state, in the logic of financial, physical and human resources efficiency.

Health Law reforms and the combining of services may lead to greater restrictions on medical treatment: for example, chronic conditions that lead to catastrophic health costs are not necessarily covered by out-patient care systems. The population's right to choose is affected when public services deteriorate, important budgets are reduced, medicines are unavailable and demand for treatment overwhelms available care; when there are few medical and paramedical personnel, long waiting lists and welfare programmes are inadequate – and so on.

The reorganisation of the public health system proposes goals – or promises – of a different order, such as increasing the coverage of medical assistance to the uninsured population, hiring a greater number of doctors, particularly in rural areas, and the free provision of all medicines instead of only a guaranteed basic pool. It also refers to the need to make transparent the acquisition of prescribed medications and the possibility of carrying out massive imports of medicines to reduce costs.

These goals would be commendable as long as they move beyond official discourse and achieve a real positive impact on public policies and specific programmes to ensure that people have effective and timely access to services, and thereby guarantee the population's right to health. However, judging by recent decisions made in public policy, budget reductions and inefficient management, I believe that serious consequences are being generated which are currently affecting the functioning of an already deficient and insufficient public health system.

There is no clear route forward and there are too many uncertainties regarding the scope and limitations of these transformations of the public health system. It is expected that serious operational, institutional and financial difficulties will arise, involving different social actors and interests, sometimes opposed to each other. It may be unrealistic or even utopian to expect that, with so many other goals still to be achieved, the Mexican government should focus serious attention on the CRP system and the need to regulate its operation.

In the light of this, it can be seen that the government has delegated part of its responsibility. It has transferred the social function of medical care to private pharmaceutical companies, which, though effective at providing services, are intrinsically commercial ventures, and therefore do so with an eye to business and profit making. In short, it is a further aspect of the global trend towards the privatisation of health and disease as a generator of market profit.

It seems difficult to reverse this privatisation process, so a comprehensive analysis of these issues is necessary. The economic cost–benefit ratio, the commercialisation of health, the expansion of the pharmaceutical industry and the retreat of the public healthcare sector are all important. Additionally, it is important not to ignore the perspective of the user population who – through the CRP system – can at least treat some of their medical issues in an effective and accessible way.

The current challenge for the Ministry of Health is the implementation of public policies that guarantee the quality of the treatment offered within this model of private care, regulating its growth and operation, reducing the problem of over-prescription and ensuring that the doctors have accredited training. The goal is to optimise this service and merge it adequately with the other public and private services in the three levels of medical care.

The state should not cede its leading role in the provision of health services and simply leave the population's needs in the hands of private enterprise, in the free market of supply and demand, where health issues are the source of major earnings for the highly profitable business of the pharmaceutical industry.

It is imperative to demand from the state better regulation and standardisation of the services offered by these clinics in order to guarantee patients high-quality and humane care. This network of private clinics could be used as a platform to implement and improve epidemiological surveillance systems, prevention programmes and health promotion campaigns that already operate in the public health system. Given the importance of their day-to-day work, the role of physicians in the CRP system needs to be restored, not only in terms of social prestige within and outside their profession, but also in improving their labour conditions.

Finally, I believe that it is fundamental to regain the perspectives of all the actors involved, the interests and needs that are at stake, and to recognise the advantages and disadvantages, possibilities and risks that this new private healthcare system can offer in the present and in the immediate future. It is a system that, for better or for worse, is doubtless here to stay.

### Notes

Marine Ministry (SEMAR); among those treated are also workers (and their familial beneficiaries) who are part of the formal economy. This system is financed by the government, the workers and, where applicable, entrepreneur-employers. Second, the public sector groups and the institutions that protect or provide services to the population outside the social security system; they are attended by the Ministry of Health (SSA), the State Health Services (SESA) and certain social assistance and protection programmes such as Seguro Popular or the IMSS-Prospera programme, which provide medical care for a basic set of health problems in order to expand healthcare coverage for the low-income population in urban and rural areas. It is financed by the federal government, and the beneficiaries may contribute minimal charges. In order to qualify, beneficiaries must comply with specific requirements. The private health sector provides services to the population with payment capacity in the three levels of care. The system of pharmacies and annexed consultation rooms is one facet of private primary healthcare.

### References

### 9 Naming, framing and shaming through obstetric violence: A critical approach to the judicialisation of maternal health rights violations in Mexico

Paola M. Sesia

Between October 2013 and September 2014, eight cases of human rights violations against Mexican women during childbirth were denounced to human rights oversight bodies by civil society organisations. Cases were petitioned at Mexico's National Commission on Human Rights (NCHR) as well as at the Inter-American Commission on Human Rights (IACHR), requesting intervention regarding the Mexican government's acts or omissions on this issue.

The violations occurred during expectant mothers' failed attempts to obtain care in the public health system, over the course of obstetric care or as a fatal consequence of the care provided, resulting in the woman's death. The majority of these cases refer to low-income, indigenous and rural women from the poorest and most marginalised states of the country, such as Oaxaca. These cases were litigated pro bono as 'public interest' or 'strategic litigation' cases (Coral-Díaz et al. 2010), that, while benefitting the victims, simultaneously sought a transformation of the Mexican healthcare system through legal mechanisms and from a rightsbased perspective.

The practice of litigating human rights violations against pregnant women is a recent phenomenon in Latin America; even more so, in Mexico. In order for this phenomenon to take place, it was first necessary to argue in the political and legal arenas that access to high-quality and respectful maternal healthcare is a right for all pregnant women. This has become even more urgent for women who have been historically and socially excluded and discriminated against. Simultaneously, in Mexico a novel type of argument was being framed, using the concept of 'obstetric violence' to name and judicialise these violations.

In this chapter, I will examine how this concept was constructed and how it has begun to be used as a tool for demanding justice in human rights oversight bodies. I will explain what we mean by judicialisation in maternal health and how this process is being broached in Mexico by analysing some characteristics and problems of the public maternal healthcare system, in order to understand the context in which judicialisation occurs.

I will analyse one specific case of a violation committed against an indigenous woman from Oaxaca, review the characteristics of the case, the timeline of its progression, the responses from health authorities and the discursive and material strategies adopted by the litigating organisation in constructing and handling the legal case. Through this example, I will share some thoughts about the achievements and limitations of judicialising violations of maternal healthcare, keeping in mind that in Mexico these are incipient, incomplete and evolving processes. In particular, I will analyse the use of obstetric violence arguments and the capacity of judicialisation as a means for compensating victims, as well as its potential for transforming health policy and healthcare delivery to make them less discriminatory and more responsive to poor indigenous women's needs and rights.

The judicialisation of human rights violations in maternal healthcare and their framing as obstetric violence provide a fruitful ground for anthropological inquiries from a critical medical anthropology (CMA) perspective. CMA can be defined as a theoretical and methodological orientation that is vigilant of structural determinants and power relations around health, illness and health-seeking and whose field of inquiry includes individual and collective responses embedded in those social determinants and relations (Seppilli and Otegui 2005).

The litigation of human rights in maternal health is a social practice that can benefit from becoming the subject of anthropological critique – even more so, when this critique is sensitive to power relations, multiple inequalities and the quest for social justice (Farmer 1999). Unlike the language and practice of law that tends to stress a formalistic, unspecific and universalist reading of human rights including the right to health, CMA provides an analytical lens that highlights their context-specific, relational, disputed, power-related and transforming (as well as transformative) nature in practice.

Moreover, and as Farmer reminds us in relation to human rights abuses, such a critique allows us to understand how violations are related to dominance and the production and reproduction of social inequalities. A CMA perspective also helps to discern the almost inevitable interplay of social class, racism and/or gender discrimination in their occurrence, including in healthcare. In Farmer's own words:

[Anthropology] permit[s] us to ground our understanding of human rights violations in broader analyses of power and social inequality. Whereas a purely legal view of human rights tends to obscure the dynamics of human rights violations, the contextualizing disciplines [anthropology, history and sociology] reveal them to be 'pathologies of power'. Social inequalities based on race or ethnicity, gender, religious creed, and – above all – social class are the motive force behind most human rights violations.

(Farmer 1999: 1488)

In particular, we can read the litigation of human rights violations in maternal healthcare through the framing of obstetric violence as a conflictive relational social field (Bourdieu and Wacquant 1995) whose discursive and material stakes are greatly disputed among multiple contenders. Here, a CMA perspective is able to unravel the power dynamics implicit in those contentions; to dissect the differing motives, reasoning and strategies of actors involved in arguing for or against the occurrence of obstetric violence in human rights violations; to understand the underlying meanings attributed to such a conceptual framing in building the legal arguments; to unpack the hegemonic social representations that coalesce around constructions of otherness attributed to subaltern social subjects such as indigenous pregnant women in the clinical encounter; to identify counter-hegemonic representations that arise in subaltern responses during the unfolding of the judicial dispute; and to highlight the socio-political consequences of those contentions and resolutions in victims' redress as well as in the transformation of the healthcare system from a rights-based perspective.

### Judicialisation, human rights and obstetric violence