Anthropology & MedicineVol. 12, No. 3, December 2005, pp. 239–254
Pharmaceutical Citizenship:Antidepressant Marketing andthe Promise of Demarginalizationin India
Among practitioners of biomedicine, to speak of people as ‘marginalized’ often amountsto saying that they do not have access to medical substances. Thus conceived, the bestway to remove marginality seems to be to give medicines to those deprived of them. The peculiar relationship between marginality and pharmaceuticals is especiallypoignant in the case of antidepressant drugs, as these drugs appear to bring the patient‘back into society’, but not any society, but middle-class consumer society. What is nowspecial about antidepressants is that there is nothing special about them: antidepressantsare like consumer items among thousands of other consumer items. This paper exploresthe relations between medicines and marginality with reference to the marketing ofantidepressant drugs in Kolkata (Calcutta), India. Drawing on ethnographic fieldworkin the Kolkata metropolitan area from July 1999 to December 2000 and in August/September 2003, this paper examines how people with depression are constitutedas ‘marginal’ in the sense of ‘being deprived of medication’, and how the biomedicalpromise of an effective pharmacological treatment becomes a promise of ‘pharmaceuticalcitizenship’. In view of Bengali notions of mental health as a state of detachment,the paper asks if pharmacological demarginalization holds the same promise in theIndian context that it holds in the West.
Over the past decade, psychiatric disease categories have been more widelypopularized than ever before. Since the 1990s, the World Health Organizationcounts depression among the world’s most pressing health problems, and predicts
Correspondence to: Dr. Stefan Ecks, Social Anthropology, School of Social and Political Studies, University
of Edinburgh, Adam Ferguson Building, George Square, Edinburgh EH8 9LL, UK. Tel.: þ44 (0)131 650 6969;Fax: þ44 (0)131 650 3945; Email: firstname.lastname@example.org
ISSN 1364-8470 (print)/ISSN 1469-2910 (online) ß 2005 Taylor & FrancisDOI: 10.1080/13648470500291360
a further increase in suffering in the years to come (Desjarlais et al. 1995; WorldHealth Organization 2001; Kirmayer & Jarvis, in press). The surge of interest indepression in the field of international health was intertwined with the emergenceof a new generation of antidepressant drugs, the serotonin reuptake inhibitors (SSRIs). The pharmaceutical industry is increasingly employing strategies of direct-to-consumer marketing, aiming to create a popular recognition of depressivesymptoms, to ‘grow the market’, and to foster a demand for specific medications. According to Healy (1999; 2004) and many other authors, we are living in‘the antidepressant era’. The rising consumption of mood-brighteners has triggereda complex bioethical debate on the advantages and dangers of these drugs.
This ongoing transformation of mental health is by no means limited to Western
countries. The pharmaceutical industry of India is becoming one of the world’sbiggest producers of pharmaceuticals, especially in the field of generic medications. India, more than any other developing country, holds ‘great pharmaceutical promise’(The Economist, 18 June 2005). Today, the industry also strongly directs itsmarketing efforts to the Indian domestic market. Indeed it seems that Westernpharmaceutical companies, faced with stiff competition from Indian companies,have so far left the antidepressant market largely to Indian firms.
As Laurence Kirmayer argues, the worldwide spread of antidepressant medications
is part of a ‘global monoculture of happiness’, which demands that everyone be‘pain free, completely comfortable, and ready and able to acquire and consume thegreatest quantity and variety of the newest goods and fashions’ (2002, p. 316). Atthe same time, supporters of antidepressant medications point out that it wouldbe perverse to speak of a global spread of these drugs. Instead, there was a large‘treatment gap’ between developed and less developed countries (World MentalHealth Survey Consortium 2004).
What are the effects of antidepressants in the Indian context? I want to raise this
question in relation to the theme of ‘marginality’. The view of marginalityexpounded by the WHO, the World Bank, NGOs, state agencies, international healthand biomedicine at large, sees marginality as a form of social inequality that should,in principle, be abolished. Whenever one speaks of ‘marginality’, one speaks of astate of injustice. To call a person or a group ‘marginal’ normally entails an ethicalmandate to remove such marginality. For example, a World Bank Report onthe Voices of the Poor (Narayan et al. 1999) uses the terms ‘marginal’ and‘marginalization’ to describe social exclusion or the unfair distribution of goodsand services. With regard to health care, to be ‘marginal’ means to be cut off fromthe circulation of biomedical substances. The voices of ‘marginalized’ people thatare quoted in the World Bank Report all speak of being unfairly deprived ofmedicines (e.g., Narayan et al. 1999, pp. 87–88, 96, 113). Marginalization, poverty,and the exclusion from social networks become virtually synonymous: ‘In explainingpoverty, poor men and women very often express a sense of hopelessness,powerlessness, humiliation, and marginalization’ (Narayan et al. 1999, p. 35). Theinclusion of ‘hopelessness’ in this sentence is no coincidence. To be ‘marginalized’does not just entail difficulties in obtaining medical care, but is also linked to agreater risk of becoming depressed in the first place (Kirmayer & Jarvis, in press, p. 12).
Being depressed is seen a symptom of being socially marginalized, and untreateddepression is seen a symptom of being marginalized from pharmaceutical networks.
One obvious conclusion that might be drawn from this understanding of depression
and marginality is that antidepressant medications should be made available—or,at least, easily affordable—for as many marginalized people as possible. A pharma-cological promise of demarginalization is evident in discussions on many diseases:malaria, tuberculosis, or antiretroviral medications. It is also prominent in thediscourse on depression in developing countries. Removing symptoms of depressionwould contribute to removing social marginality, and vice versa. Offering apharmaceutical substance to those at the margins is defined as the best way to helpthem. The definition of marginalization that the World Bank puts forth is typical ofa ‘monoculture of happiness’ which defines happiness in terms of consumerism:here, the consumption of pharmaceuticals.
Recent discussions of the relation between medicine and society have focused on theterm ‘biological citizenship’ (e.g., Petryna 2002; Rose & Novas 2004). Citizenship,it is argued, should not only be considered as the link between an individual personand a nation state. Instead, it is a complex process of overlapping ‘citizenshipprojects’ that is not limited to the politico-legal sphere. ‘Biological’ citizenship isone of these projects, centred on biomedicine and new forms of biotechnology. In reference to this, I want to define one form of biological citizenship as‘pharmaceutical citizenship’. The biomedical promise of demarginalization can beseen as one among several current citizenship projects that redefine belonging,exclusion, duties and rights. Pharmaceutical citizenship revolves around twoquestions. Firstly, how does legal citizenship determine rights of access topharmaceuticals? This includes, for example, the issue if equality between citizensalso means equal entitlement to receive drugs. Secondly, what implications doesthe taking of pharmaceuticals have for a person’s status as a citizen? Questionshere include whether the taking of certain pharmaceuticals, such as various psycho-tropics, impairs one’s rights as a fully responsible citizen, or whether patients canonly regain full citizenship rights if they undergo pharmacological treatment.
In India, the project of pharmaceutical citizenship is closely linked to other such
ventures. In the discourse on democratic voting rights in India, Dipesh Chakrabarty(2000) discerns two rival notions of the ‘citizen’. The first is the peasant-as-citizenwho, despite lacking education, is already a full citizen and entitled to vote. Thesecond is the not-yet-citizen peasant who still ‘has to be educated into the citizen’(2000, p. 10). This position holds that without proper education, Indian democracywill never fulfil its promise. I would argue that pharmaceutical citizenship entails asimilar friction, between the citizen-as-patient who is entitled to medicines becausehe or she is already a full citizen, and the not-yet-citizen patient, for whom the takingof medicines becomes a practice of becoming a full citizen. In pharmaceuticalcitizenship, the role of civic education is replaced by medical marketing.
The notion of pharmaceutical citizenship is particularly poignant in the case of
antidepressant medicines. Even in developed countries, the message promoted by thepharmaceutical industry is that antidepressants have the power to demarginalize thesuffering individual and to restore his ‘own true self’. For example, an Americandirect-to-consumer campaign for the antidepressant drug Paxil used as its slogan‘I feel like myself again’. Being oneself again means, above all, to overcome theisolating effects of depression and to be able to reintegrate oneself into society(Dumit 2003). More than other medicines, antidepressants hold the promise ofa quick and effective demarginalization.1
The promise of demarginalization through antidepressants is a leading theme
in the marketing strategies of Indian pharmaceutical companies. In the following,I discuss Indian pharmaceutical advertisements that I collected in 2003. AlthoughI cannot discuss more than four examples here, I believe that they are representativefor antidepressant marketing in India generally. The first ad is for the antidepressantPaxidep CR (Symbiosis/Sun Pharma), the second for the brand Arpizol (Synergy/Sun Pharma), the third for Firsito (Zydus Neurosciences), and the fourth for Aripra(Solus/Ranbaxy). All these advertisements are targeted at doctors in general practiceand mental health professionals. They all feature the brand name, the companylogo, and the active substances in various available doses. None of them entailsa picture of the tablet/capsule itself.
The ad for Paxidep CR gives explicit details of the advantages of this drug:
significant improvement of symptoms already in the first week of treatment;‘56% remission rates’ starting from the third week; ‘unmatched GI [gastro-intestinal]tolerability’ thanks to a special coating; and several more. The catchphrase ofPaxidep CR is ‘Live . . . every moment . . . with confidence’. An image in the adshows a twenty-something couple, a man and a woman, holding hands with a childbetween them, smiling and dancing. The ad for Arpizol dubs the drug ‘The 1stdopamine serotonin system modulator’. Instead of describing the properties of thedrug, it just shows an image of a smiling young man, on all fours on a well-polishedwooden floor with a child, presumably his son, riding piggyback on him. The drugFirsito is advertised as ‘First Choice’, and touts its active ingredient: ‘Escitalopramin the treatment of severe depression’. Half of the ad consists of a photo in whicha man cheerily spoon-feeds ice cream to his female partner. The fourth ad, for thedrug Aripra, says that it is ‘For A Beautiful Mind & Beyond . . . ’ and includes aphotograph of a smiling male/female couple, both of whose eyes are fixed on a pointbeyond the horizon.
What I want to highlight are the images of the people. All of them look like
attractive, smiling, fair-skinned South Asians. They are not depicted as isolatedindividuals, but in cheerful company with their partners or their children. They areall engaged in some sort of play: feeding ice cream to each other, joking, dancing,and holding hands. They all wear Western clothes and seem to be well off or evenrich. Neither of the pictures shows the medicines themselves, nor the act of ingestingthe capsules. In each case, it is impossible to tell who is taking the medication: isit the man, the woman, or the child? The medication seems to bring one backinto society without stigma or visible mark. No hint of any ‘marginal’ social
status is evident. Revealingly, the only type of person to reappear in all four ads isthe male adult—if there is one group which is by far the least ‘marginal’ in India,it is that of the middle-/upper-class male family father. In India, as in many othercountries, men are less likely to be depressed than women (e.g., Stoppard 2000).
These images contain no trace of marginality (be it marginality on the grounds of
class, caste, gender, or stigmatizing mental illness). They suggest that the drugremoves both depression and all forms of marginality. They promise not just therelief of depressive symptoms, but full mental, physical, and economic integration. ‘Reintegrating Lives’, the motto of Zydus Neurosciences, further underlines thismission. The promise of demarginalization is not limited to mental health, but toone’s social status in general. The message seems to be: ‘Take this medicine, and youwill not only be happy, but married with children, rich, and live a Western life-style’. Being one’s own ‘true self’ in India seems to mean being a middle-class subject cladin Western clothes. Of course, the same message can be found in advertisements forcars, fridges, or washing powder, which all engage images of happy middle-classselves (cf. Mazzarella 2003). What is special about antidepressants is that there isnothing special about them: antidepressants are like consumer items amongthousands of other consumer items. The grey past of suffering has passed, and anew age of middle-class happiness has come.
Similar structures also appear in forms of marketing directly aimed at consumers.
One type of this is the ‘self-test’ for mental health. Most self-tests do not advertisea specific product but aim to ‘grow the market’ for antidepressants generally. For example, a leaflet distributed by a Mumbai-based company is entitled ‘TheDepression Self Test’. On the front, it shows a big ‘smiley’ face encircled by thewords: ‘Defeat Depression—Spread Happiness’ and underlines that it is ‘FREE!’(suggesting that people would usually pay for a test like this). On the back, a list often items for self-diagnosis is presented. Whoever experiences ‘five or more’ of thefollowing symptoms is told to ‘see your doctor’:
. A persistent sad, anxious, or ‘empty’ mood. Sleeping too little or too much. Reduced appetite and weight loss or increased appetite and weight gain. Loss of interest or pleasure in activities once enjoyed. Restlessness or irritability. Persistent physical symptoms that don’t respond to treatment. Difficulty concentrating, remembering or making decisions. Fatigue or loss of energy. Feeling guilty, hopeless or worthless. Recurrent thoughts of death/suicidal attempt
The leaflet was produced and distributed by Ipca Labs Ltd., a company that
produces a range of psychotropic drugs, among them antidepressants. In 2000,Ipca Labs set up a special division for ‘therapy-focused marketing of neuropsychia-tric drugs’. Creating consumer awareness of mental health problems is one of thisdivision’s main marketing activities. Although the leaflet lists symptoms of depres-sion that correspond to psychiatric classifications, it seems that the company spreads
a rather inflated understanding of depression. Especially the scaling of the answersseems questionable: if a person experiences ‘five or more’ out of ten symptoms, heor she is advised to seek medical help. The general way in which the questionsare asked raises the suspicion that even people who would not fall into the categoryof ‘depression’ if diagnosed by a professional psychiatrist might be pushed to believethat they are depressed and in need of medicines.2
It might appear that the leaflet simply shifts the focus from social marginality to
individual pathology. But rather than suggesting individual pathology, it promisesglobal pharmaceutical citizenship. Firstly, while policy makers portray Indian healthcare as marginal to global health care, the language used in the leaflet is English. ‘Your doctor’ is someone around the corner in Kolkata, someone who commandsthe same psychiatric expertise as doctors in Europe or in America. Second, nomention is made of local idioms of distress; nothing is said about an Indian contextof diagnosing and treating depression. Third, depression is not associated with‘marginal’ groups within India, e.g. low-class women or migrant workers, groupsthat might be more prone to depression than others. Instead, the ‘you’ of the textcould be anyone. Perhaps an unwitting yet telling trait of the flyer is the ‘smiley face’,a kind of generic global representation of ‘face’ without any trace of difference, beit class-based, ethnic, gendered, or other.3
The ‘Depression Self-Test’ tries to convince its readers that depression is a disease,
that it is widespread, and that it is largely undiagnosed. Those who are defined asdepressed are defined as marginal to society, as long as they do not go to see adoctor and get medicated. The promise of demarginalization comes in form of‘your doctor’, able to prescribe a medicine. The blurring of boundaries between thenormal and the pathological through antidepressants takes on a new spin in relationto marginality. The aim of the flyer is to make as many people feel ‘depressed’, andhence ‘marginal’ to society, as possible. Re-entry into society, it is suggested, is bestpossible with the help of medicine. But the ‘society’ that one will re-enter is not anysociety, but mainstream middle-class consumer society in tune with the globalmonoculture of happiness. This could be one critical reading of pharmaceuticalmarketing in India.
No doubt, there is among social scientists—and perhaps especially among medicalanthropologists—a deep distrust of any purely pharmacological form of overcomingmarginality. Nichter and Vuckovic express this position clearly when they assert that‘pharmaceutical fixes of diseases often constitute the path of least resistance incontexts of underdevelopment’ (1994, p. 1512). Giving a substance is a superficialsolution to problems of marginality. For most anthropologists, the prescriptionof antidepressants for the ills of marginality would amount to a quick fix at best,and a new form of exploitation by pharmaceutical companies at worst. Anantidepressant, the critique would run, is nothing but a fetishized commodity thatdiverts our attention away from unequal relations between humans and humans,while disguising them as relations between things and humans. This Marx-inspired4
suspicion of commodities as fetishes still runs deep in current anthropology(Downey et al. 1995, p. 267). It would seem that, in the debate about antidepressantsas a means of demarginalization, we are left with two main positions. On the oneside, most biomedical practitioners, the pharmaceutical industries, and publichealth organizations would now support antidepressants as a relatively effectiveway to remove marginality. On the other side, many social scientists would seeantidepressants as fetishes of medicine that eschew solving the ‘real’ problems, whichare essentially problems of social inequality.
Recently, Bruno Latour (2004) renewed his proposals to overcome thinking in
such dichotomies. Concerned by reactionary appropriations of sociological views ofscience as ‘constructed’, Latour asks if critical social theory of science needs torethink itself. For him, the social-constructivist critique of science works like a kindof ‘potent euphoric drug’ (Latour 2004, p. 163) for those who use it, because it isalways right. Any object that the critic politically dislikes can be branded a ‘fetish’and be discarded as useless: ‘When naı¨ve believers are clinging forcefully to theirobjects, claiming that they are made to do things . . . you can turn all of thoseattachments into so many fetishes and humiliate all the believers by showing thatit is nothing but their own projection’ (Latour 2004, p. 163). In the caseof antidepressants, the obvious social science critique is to call them ‘fetishes’ ofmedicine, development, and pharmaceutical industries. What should be done, inLatour’s view, is to see matters of fact as matters of concern for all thoseparticipating. If his point is to be applied, however, we have to find a way to thinkabout mental health that neither reduces it to the proper distribution of medicines,nor simply rejects medicines as fetishized commodities.
In recent years, the anthropologies of science, technology, and medicine have done
much to illustrate the argument that the separation between the authentic/humanand the inauthentic/non-human domains can be misleading. For example, Rabinow(1996, pp. 99–102) shows how scientific artefacts can generate the emergence of‘biosocialities’ such as patient interest groups. Clarke et al. (2003) show how newforms of medicalization can trigger the appearance of new ‘risk-based, genomics-based, epidemiology-based, and other technoscience-based identities’ (Clarke et al. 2003, p. 182). These technoscientific identities are not formed by patients in orderto ‘resist’ medicine, but already represent a basic acceptance of biomedical notionsof self and health (Rose & Novas 2004, p. 449).
Drawing on these works, I think that medical anthropologists should not be too
quick to separate human actors (patients, doctors, et al.) from non-human actors(for example, antidepressants). Instead, it might be more fruitful to followpharmaceuticals around and to study their power of not only transforming thebodies and moods of individuals, but of transforming social relations as well(Whyte et al. 2002; Ecks 2003). Before returning to antidepressants in India, I wantto illustrate this point with an analysis of one seminal North American text onantidepressants: the Beyond Therapy Report (The President’s Council on Bioethics2003). A close reading of this report will make it possible to see some of the faultlines of current thought on antidepressants in the West. Since Indian pharmaceuticalcompanies model their marketing strategies along Western examples, any approach
to the Indian context must take a global perspective. The main idea of the Report,that true healing of depression can only be achieved through reintegration, will serveas a point for comparison with examples from India later in this paper.
American Bioethics of ‘True Happiness’
One of the most influential statements on the bioethics of antidepressants waspublished in October 2003 by the U.S. American President’s Council on Bioethics. The Report, entitled Beyond Therapy: Biotechnology and the Pursuit of Happiness(also named ‘Kass Report’ after the Council’s chairman, Leon Kass), presents anuanced discussion of medical technologies that promise to make people not justwell, but ‘better than well’. Taking its chief inspiration from the AmericanDeclaration of Independence, the Report defines the pursuit of happiness as a basichuman right: ‘the right to pursue happiness is one of the unalienable rightsthat belong equally to all human beings’ (The President’s Council on Bioethics2003, p. 203). Happiness is seen not as one goal in life among others, but as an‘overarching interest in our complete and comprehensive well-being’ (ThePresident’s Council on Bioethics 2003, p. 203).5
Along with ‘Better Children’, ‘Superior Performance’, and ‘Ageless Bodies’, the
problem of ‘Happy Souls’ is one of the main concerns of the Report. Drawing ona variety of statistical data, the Report holds that up to twenty percent of all U.S. Americans were suffering from ‘some form of depression’ (The President’s Councilon Bioethics 2003, p. 240). The constant rise in the number of people who arediagnosed as depressive was a true increase in suffering. Hence it was neither anartificial outcome of changing diagnostics (especially the widening of the ‘depression’classification), nor an outcome of different statistical methods. Although the numberof people who receive antidepressant medication had also increased dramatically,depression was still ‘undertreated’ (The President’s Council on Bioethics 2003,p. 240). Placing great faith in future advances in pharmacological treatments, theKass Report predicts a rapid further spreading of antidepressant prescriptions.
By itself, the expansion of antidepressants is not seen as an ethical problem, as long
as they relieve ‘true’ suffering. The ethical dilemma only arises when people who do not‘truly’ suffer start taking these pills. To a certain extent, low moods, sadness, andfeelings of hopelessness were all part of ‘normal’ life, and should be accepted as such. These were crises that reflect the truth of human existence. Suppressing them throughthe use of antidepressants entailed the risk of ‘undermining our true identity’(The President’s Council on Bioethics, 2003, p. 225). The most pressing ethicalproblem, then, is to distinguish between true (objective, clinically proven) suffering,and merely subjective, inauthentic suffering. To draw this distinction is, of course,very difficult, as the Report acknowledges: ‘How can one tell the difference betweentrue and false happiness, between the real thing and the mere likeness?’ (p. 209).
The term ‘true’ plays a pivotal role in the Report’s line of argument. Separating
truth from falsehood is seen a major concern of our lives: ‘In human affairs, wecare a great deal about the difference between ‘‘the real’’ and ‘‘the mere appearing’’. We care about ‘‘living truly’’’ (The President’s Council on Bioethics 2003, p. 251).
The Report hopes that it can rediscover ‘the true meaning of our founding ideals’(2003, p. xiv) about happiness while still savouring the fruits of biomedicine.
If ‘living truly’ is so essential, how should we live truly? The answer that the
Report develops is this: true life is life with other people, a deeply committed sociallife. The route to authentic happiness is to live one’s life engaged with other humans. The Report states that ‘we’ do not want to be happy because of pills, but onlybecause of ‘real loves, attachments, and achievements that are essential for truehuman flourishing’ (2003, p. xiii). True happiness can only flow from ‘the ties thatbind and that ultimately give the individual’s identity its true shape’ (2003, p. 265).
In its discussion of happiness, the Report leaves aside all questions of class, race,
gender, or any other forms of social inequality. Even so, its findings directly answerthe question if antidepressants could be a means of overcoming social marginality. For the Report, authentic happiness comes first through rebuilding and strengthen-ing our social ties and engagement with the world. Only if this fails is it justifiableto use pharmaceuticals. Without strengthening social ties, taking pharmaceuticalsentails the risk of even deeper alienation. Health is not to be commodified, but ratherto be realized through social reintegration.
Even if most anthropologists would shy away from such frequent use of the term
‘true’, I suppose that they will readily agree with the Report’s conclusions. Manymedical advocates of antidepressants, including representatives of the pharmaceuticalindustry, might also concur with its insistence that ‘true’ happiness is not to beachieved through drugs alone. In my view, however, the Kass Report does not reflectdeeply enough on its own definitions of ‘true’ or ‘authentic’ happiness. In theReport, the distinction between ‘authentic’ and ‘inauthentic’ forms comes down toa distinction between the ‘true’ happiness that is achieved on a human level and the‘false’ (or at least ambiguous) happiness that is won through ingesting non-humansubstances such as antidepressants. In this perspective, reintegration throughpharmaceuticals seems ambiguous because it is not purely social.
What is easily overlooked is that this definition of authentic happiness is already
mediated by the presence of mood-brightening drugs. If ‘authentic happiness’ isrooted in social ties, what does ‘social’ mean? The very definition of ‘social ties’ usedin the Kass Report is based on an implicit exclusion of drugs. ‘Social’ is then a spacewhere non-human substances are not admitted to enter and where only relationsbetween humans are allowed. Human relations produce ‘authentic’ happiness,whereas relations between humans and non-humans can only produce a semblanceof it. Humans can only be truly reintegrated when non-human antidepressantsare, in a manner of speaking, marginalized from human society. The Kass Report’sdefinition of true happiness relies on the crossing out of pharmaceuticals asinauthentic non-humans. Is such a sociocentric definition of true happinesssufficient to understand concepts to mental health in India?
The Kass Report is only concerned with the situation in the United States and doesnot discuss mental health in a transcultural perspective. Yet the questions it raises,
for example about the boundaries of the category ‘depression,’ also apply totranscultural psychiatry. In the remainder of this paper, I want to open a com-parative perspective on the ethical concerns around antidepressants, especially inrelation to ‘true happiness’.
How to measure the occurrence of mental illness cross-culturally, without falsely
imposing a set of Western preconceptions, remains a controversial problem(cf. Kleinman & Good 1985; Dawson & Tylee 2001; Weiss 2001). One of theproposed solutions to the problem of cross-cultural difference is to take account oflocal idioms of distress in the assessment. The inclusion of such idioms in thefourth edition of the American Psychiatric Association’s Diagnostic and StatisticalManual (DSM-IV) is a working example of this process (cf. Mezzich et al. 1999).
For India, idioms such as ‘feeling hot’, ‘gas’ or ‘semen loss’ have been identified as
local ways of experiencing and expressing depression (cf. Mumford 1996; Raguramet al. 1996; Bhugra & Mastrogianni 2004). Even if these cultural idioms have theirown aetiology and symptomatology, they are at least seen as local approximations. Psychiatrists who are most doubtful of the universality of Western psychiatriccategories suggest that we should ‘step back from the received categories ofpsychiatric nosology and begin again with ethnographic research on local waysof expressing distress’ (Kirmayer & Jarvis, in press, p. 3). One of these expressionsof distress I want to focus on here is the Bengali term mon kharap (‘bad mind’).
During fieldwork in Kolkata (1999–2000 and 2003), I explored Bengali expressions
for problems relating to the ‘mind’ (mon). Bengalis have an elaborate languagefor experiences of sadness (dukkho), anxiety (dush cinta), the inability to makedecisions, loss of joy in life, and many other problems. People speak frequently andfreely about experiencing a mon kharap (‘bad mind’). Mon is the Bengali term formind (or ‘heart–mind’), mood, affection, concentration, intention, and personalopinion. It is etymologically related to Sanskrit manas, Greek menos, Latin mens,and English mind. Bengali mon does not have a specific location within the body. When people use the term, they either point to the solar plexus area of the chest,point to the forehead, or move their hand between these two points. Mon kharapseems to be the most general and inclusive category for sadness, grief, irritability,anxiety, and the inability to make decisions.
Despite many similarities, it is not possible to reduce mon either to a psychological
entity, nor to interpret mon kharap as an equivalent of ‘depression’. Instead, monkharap covers a broad construct of dysphoria and distress that can include both. Similarly, other idioms of distress (e.g. ‘gastric’) that seem like symptoms ofdepression cannot be easily subsumed under the rubric of this psychiatric diseasecategory. Specifically, ‘gastric’ is not simply a somatic idiom of depression.
The psychiatric notion that Indians ‘somatize’ psychological problems by speaking
about bodily symptoms such as ‘gas’, ‘gastric’, or indigestion, is misleading. Firstly,the observation that Indian patients tend to present bodily symptoms insteadof ‘psychological’ ones in biomedical consultations is correct, but is not due to a laymisrecognition of the symptoms. Instead, it is due to the perception that biomedicaltreatments are best suited to treat physiological symptoms—problems of theheart–mind are not seen to be its specialty area (cf. Jadhav et al. 2001).
Second, proper digestion, with or without somatopsychic connotations, occupies
a central place in Bengali concepts of health and well-being (Ecks 2004). To put itsimply, if the belly is all right, all one’s health is all right. Yet as the body’s internalkitchen or cooking-place, always yearning to be filled, the belly constantly threatensto overheat, to become imbalanced, and to get out of control. The ‘hot’ tendenciesof the belly can only be held in check by the ‘cooling’ influences of the mind. As isclear from countless Bengali metaphors, the characteristics of mon are seen to bediametrically opposed to those of the belly. Where the belly exerts an animal-likeagency, mon brings the person closer to the gods. The belly desires to be filled andto be fed, whereas the mind aims to take in as little as possible. Where the bellyis moving and heating, the ideal mon is cool and still. The belly constantly threatensa person’s self-control, whereas the mon can bring self-control.6
For this reason, good health depends on a proper alignment of mind and belly.
Keeping the mind sane will keep the belly sane, and vice versa. A disturbance ofthe belly can be treated with pharmaceuticals, yet a disturbance of mon is generallyseen as being beyond the expertise of medicine, and non-medical practices suchas praying or doing worship ( puja) are usually seen as far more effective than goingto see a doctor.7 Hence it becomes understandable how the frequent presentationof ‘gastric’ complaints in the doctor–patient encounter cannot be translated intoa somatic ‘misrecognition’ of mental imbalance by the patient.
Let me back up these insights from long-term participant observation with results
from semi-structured interviews that I conducted with 40 residents of Uttarpara, anorthern suburb of Kolkata, in 2003. One of the questions I asked in these interviewswas about the most effective forms of relief from mon kharap. Twenty womenand twenty men were interviewed, all of them Hindu Bengalis, most of themlower-middle and middle-class. By far the most commonly mentioned relief frommon kharap was prayer to deities (27 out of 40 responses). Other religious practiceswere also frequently mentioned, e.g. visiting temples (16 out of 40), or readingreligious books (9 out of 40). Practices aiming primarily at calming and focusingone’s mon that are not necessarily religious were also prominent, especiallywithdrawing oneself for taking rest (21 out of 40), trying to think positively (17 outof 40), and dedicating time for meditation (6 out of 40). Drawing on social ties wasalso seen as soothing, especially seeking family support (19 out of 40) and seekingsupport from friends (14 out of 40). Resort to professional healers was rarely seen asan appropriate way to deal with mon kharap. More of my respondents recommendedvisiting an astrologer (7 out of 40) for a mon kharap than visiting a biomedicaldoctor (5 out of 40). Going to a mental health specialist as a way to relieve thesuffering of mon kharap was only mentioned by only two out of 40 people. Indeed, my questions about medical help for a mon kharap were often greeted withbemused surprise: ‘What’s got a doctor to do with mon kharap?’, one lower-classwomen replied.
There are four caveats that I should make. Firstly, Kolkata is one of the largest
urban agglomerations in the world. Given the relatively small number of peopleinterviewed, I am not claiming that these findings are statistically representativefor a population as large and diverse as Kolkata’s. Secondly, there is no reason to
assume an unchanging, ‘Bengali’ view on mental health. There are many reasonsto believe that the biomedical view of the brain is beginning to have a profoundinfluence on popular perceptions, and today the use of psychotropic medications isalready widespread among the educated elite. Thirdly, what people say they do andwhat they actually do is not necessarily the same. So what these interviews reflectis first of all a particular ideology of the self. Fourthly, what people say theywant might not be what they might ‘truly’ want if sufficient psychiatric care wasavailable and accessible (this is many psychiatrists’ point of view).
The main claims I would venture to make here are that, by and large, Hindu
Bengalis of Kolkata do not yet see symptoms of a mon kharap as a ‘medical problem’,and that the local view of mental health sees a hierarchy of effectiveness with spiritualtranscendence at the top, ties with other humans in the middle, and things/pharmaceuticals at the bottom. Strengthening one’s ties to family and friends as arelief from mon kharap are also seen as important, but not as important as practicesthat help to focus one’s mind. Going back to the discussion of Latour (2004) above,I would argue that not only pills have to be re-admitted into the picture, butalso gods and transcendent entities. A purely sociocentric view will not hold(cf. Chakrabarty 2000, p. 16).
I introduced the notion of mon kharap as a ‘local’ way of expressing distress.
Nevertheless, mon kharap resonates with much wider concerns in popular Hinduismacross India. Achieving control over one’s mind and various forms of meditativewithdrawal from the world are a central element in all strands of Hinduism(Michaels 1998, pp. 347–377). Virtually all the major figures of modern Hinduism,for example Sri Ramakrishna, Sri Aurobindo, and even M. K. Gandhi, emphasizedmind-control as a path to enlightenment, freedom, and ‘true happiness’.
That relations between humans and humans are seen as less powerful healing forces
than relations between gods (or complete transcendence) and humans, is clearer fromreligious writings. Let me give a brief quotation from the works of Swami Vivekananda(1863–1902), a disciple of Sri Ramakrishna, founder of the Kolkata-basedRamakrishna Mission, and perhaps the most famous representative of modernHinduism in the West.8 Presented alongside quotations from the Bhagavad Gita andother classical texts of Hinduism, quotations from Vivekananda’s works featureprominently in a type of religious self-care literature that is hugely popular amongKolkatans. Vivekananda is also invoked to endorse all sorts of commercial, political,and social activities. Sayings and images of Vivekananda even feature in pharma-ceutical advertising. For example, the Bengal-based company Pharmagen usesan image of Vivekananda in one of its marketing posters, which features thePharmagen logo alongside an image of Vivekananda in meditation and a quotationfrom his works: ‘The world is in need of those whose life is one of burning love, selfless’.
Vivekananda reformulated Hindu teachings in relation to the capitalist trans-
formation of India during the colonial period. He stressed, more than other religiousleaders, the importance of working with and for other people. Yet like other religiousfigures, Vivekananda also saw the root of ‘true happiness’9 in detaching oneself fromsocial ties, not in strengthening them.10 Working for others is not meant to reinforceone’s bonds with other humans, because waiting for reciprocity from others only
leads to misery. ‘True happiness’ consists in doing work without expecting anythingin return. Doing work and getting involved in the world should only be a practice ofovercoming selfishness. Ultimately, true happiness cannot be derived from social ties,but only from unravelling the ties that bind:
We are attached to our friends, to our relatives . . . What . . . brings misery but thisvery attachment? We have to detach ourselves to earn joy . . . We get caught. How?Not by what we give, but by what we expect. We get misery in return for ourlove . . . Desire, want, is the father of all misery. Desires are bound by the laws of successand failure. Desires must bring misery. The great secret of true success, of truehappiness, then, is this: the man who asks for no return, the perfectly unselfish man,is the most successful (Vivekananda 2003 , pp. 3–5).
The fact that support from family and friends is seen as a relief from mon kharap
does not mean that these social ties are taken to be the ultimate source of truehappiness. In Hindu (especially Advaita Vedanta) ideology, the ‘true shape’ of theself can only emerge when social ties are severed and the soul (atma) is releasedfrom the world into blissful union with Brahma. A person’s true shape is thetranscendence of all shapes.
In this perspective, the North American notion of true happiness emerging
from ‘the ties that bind and that ultimately give the individual’s identity its trueshape’ (The President’s Council on Bioethics 2003, p. 265) might not be sharedby Kolkatans in a straightforward way.11 Any promise of demarginalization, be it bymeans of stronger social ties or by means of antidepressants, might not be perceivedas a path to ultimate happiness.
The global monoculture of happiness does not only come in the guise of things like
antidepressants, but also in the guise of a sociocentric ideology that propagates socialties as the only path to true happiness. Promises of demarginalization through‘pharmaceutical citizenship’ are key elements in this ideology. Critiques of commodityfetishism, with its stress on social ties, might inadvertently deepen this monoculture.
The global spread of antidepressant medication changes not only the definitions
of mental health and illness, but also changes the parameters of what ‘true happiness’means. Giving pharmaceuticals as a quick way out of marginality is a notion thatmight already be common sense among Kolkata’s doctors and public health officials. It is likely that the perception of depression as a physiological disease that can betreated by antidepressant medicines will increase in the future, especially amongthe globally connected Bengali middle and upper classes. If, however, Bengali notionsof happiness are also changing towards ‘social ties’ as their vital source remains to beseen. The promise of spiritual detachment might be ultimately more alluring thanthe promise of pharmaceutical citizenship.
I would like to thank Bo Sax, Jan Weinhold, Laurence Kirmayer, Mitchell Weiss,Christine Kupfer and the participants of the conference The Ills of Marginality(IWH Heidelberg, June 2004) for their helpful suggestions. I also want to thankAnirban and Rumela Das for all their support, and Arijit Chakraborty for his
assistance during fieldwork. Research grants from the Economic and SocialScience Research Council and the South Asia Institute (Heidelberg) are gratefullyacknowledged.
 Pharmaceutical marketing is centred on substances, but is not limited to them. For example,
the website for Prozac maintained by Eli Lilly presents itself as a comprehensive sourceof information and guidance on all aspects of depression. It seeks to explain how depressionis caused by an imbalance of neurotransmitters, and how antidepressants act to restorethis balance. Crucially, it also urges people with depression to become ‘active participants’in their recovery process by keeping a diary, reducing stress, exercising, and by joiningsupport groups. Prozac’s ‘political economy of hope’ (Rose & Novas 2004, p. 447) is centredon drugs, but is not limited to them. Similarly, a marketing campaign for the schizophreniadrug Risperdal aimed not just at medication but at ‘reinsertion’ of patients throughcompany-sponsored work schemes (Lakoff 2004, p. 205).
 Self-diagnosis as a form of marketing is used not only by pharmaceutical companies, and
not just for commercial purposes. For example, the current ‘Mental Health Guide’ leafletdistributed by the counselling service of the University of Edinburgh also starts off witha self-test for depression. The problematic relation between for-profit pharmaceuticalmarketing and not-for-profit counselling services is an issue that cannot be discussed here.
 Obviously, the company has no interest in claiming that marginal people (say,
lower-class women) are particularly affected if these people are unlikely to pay for thesemedicines. I think, however, that the pharmaceutical industry’s promise of ‘pharmaceuticalcitizenship’ is the more important motive for this kind of representation.
 Most critiques of ‘commodity fetishism’ are not strictly Marxist, but are humanism in
a Marxist idiom (Anirban Das, personal communication).
 For Carl Elliott, the era of anti-depressants is an era that gives primacy, not to the right to
pursue happiness, but to the social obligation to pursue happiness, by any means necessary. In this view, which is perhaps particularly prominent in the United States, a life withouthappiness a life wasted (Elliott 2003, p. 303; cf. Elliott & Chambers 2004).
 The relation between mon and belly shares certain aspects of mind/body dualisms prevalent
in the West (cf. Kirmayer 1988), but is still different. For example, mon is just one layerof consciousness among several others. The perspective described here is simply the mostcommon and commonsensical.
 It is important to add that a mon kharap is perceived by Hindu Bengalis as a unwelcome
affliction. It is not, as Obeyesekere (1985) argues for depression-like feelings of hopelessnessand loss in Buddhist culture valued as a positive sign of unfolding wisdom about theimpermanence of the world.
 For example, at the 2005 commencement ceremony of the Massachusetts Institute
of Technology, Swami Tyagananda of the Ramakrishna Mission opened his speech witha quote from Vivekananda: ‘Education is the manifestation of the perfection alreadywithin us’. This was the first time in the history of the MIT that a Hindu priest said prayersat this ceremony (The Telegraph, Kolkata, 12 June 2005).
 The texts presented here were originally written by Vivekananda in English; hence
‘true happiness’ is his own expression and not a translation from Bengali.
 Much has been written on Indian ‘fluid bodies’ and the great importance of social
transactions in the constitution of the self (Marriott 1976; Daniel 1984; cf. Langford2002). However, none of these works on relational selves has put into questionthat pulling oneself out of worldly entanglements is still seen as the supreme goal bymost Hindus in Bengal and beyond.
 I want to underline again that ‘detachment’ is more of an ideology than a practice.
Those who ‘detach’ themselves from the world, either for a few minutes or until the restof their days, do not leave all social ties behind. Meditation is often done in groups; singingdevotional songs or celebrating puja can be a deeply social activity; and going on pilgrimageusually involves several other close members of the family or friends. Nevertheless, all ofthese activities are built on an ideology of severing social ties. This is a much-debatedpoint in Indian sociology and cannot be treated in detail here.
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JAMA, Free Speech, and Conflicts of Interest # Springer Science + Business Media, LLC 2009I recently co-authored a letter to the BMJ, pointing out anincrease the market share for Lexapro, the idea of prophy-author’s undisclosed conflict of interest related to a studylactically medicating a large group of people with nopsychiatric diagnosis so that a minority of them will notlished in the
Primary Immunodeficiencies MEGAN A. COOPER, PH.D., The Ohio State University College of Medicine and Public Health, Columbus, Ohio THOMAS L. POMMERING, D.O., Grant Family Practice Residency, Columbus, Ohio KATALIN KORÁNYI, M.D., Children’s Hospital, Columbus, Ohio Primary immunodeficiencies include a variety of disorders that render patients more susceptible to infections. If left untreate