2“Medicines” are substances used in treating illness. In this article we want to suggest that the “charm” of medicines, both in the Western world and developing countries, arises from their concreteness as substances. Medicines are things. In making this our point of departure, we are able to understand why it is that medicines are the hard core of therapy and what it is that sets them apart from other forms of healing. ln biomedicine, other kinds of treatment also have the quality of being tangible; surgery is a prime example. But surgery is not a thing that can be separated from the surgeon. It is professional and esoteric, while the “thinginess” (cf. Ellen 1988) of medicines makes them “democratic” and exoteric. That “democratic” character bas to do with the fact that medicines are widely believed to contain the power ofhealing in themselves. Anyone who gains access to them can apply their power.

3After setting the stage for our argument, we examine the charms of medicines in four steps. First, we show that as things, medicines have implications for social relations. They permit therapy to be separated from the social relations in which it might otherwise be embedded. Second, we discuss medicines as commodities, the value of which is agreed upon and transactable, but the specific meaning of which is variable. As concrete substances, medicines are “good to think with”; in our third and fourth sections, we consider the ways they carry meaning in terms of metaphoric and metonymic associations. We argue that in both metaphoric and metonymic senses, medicines enhance the perception of illness as something tangible, which may be manipulated. In moving from one context to another, they carry metonymic associations with knowledgeable doctors and technologically sophisticated centers of production.

The Popularity of Medicines

4Medicines are considered so essential to health care, that a health care program without them is almost an impossibility. In a review of essential drug programs in developing countries, Mamdani & Walker stress curative medication as the “carrot” that attracts people to primary health care (PHC):

• 2 In UNICEF’s “Bamako Initiative,” “One key factor in the increased use of health services is restor (...)

The success of PHC workers in their promotive and preventive roles depends, to a large extent, on their ability to provide credible front-line curative services. This in tum necessitates a constant timely supply of appropriate drugs in adequate amounts. [1985: l ]2

5When medicines are lacking, people stop visiting health care services, for medicines are seen as the essence of health care. A clinic without medicines is, one could say, like a bar without beer. Melrose, reviewing the sorry state of public supplies of medicines in various countries, remarked,

The most obvious consequence of rural dispensaries running out of drugs is that people stop going to them. Meanwhile govemments have to go on paying for health facilities that are under-used and paramedics find it double hard gaining acceptance as health educators when they cannot deliver basic drugs. [1982:183]

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6As these examples suggest, the “charms” of medicines are widely appreciated. What makes them so desireable? Of course, they are biologically efficacious. The impact of antibiotics on bacterial diseases bas been spectacular, particularly in Third World countries. lt is not unlikely that the efficacy of a few drugs bas been overgeneralized so that even inefficacious and harmful products are in demand. Leslie (1988) reports that in Bangladesh about 75 million dollars were spent on allopathie drugs in 1981 (60% of the total health expenditure in the country). Yet an Expert Committee estimated that 70% of these drugs would be described as therapeutically useless by authorities in Great Britain or the United States. Not only are many medicines used in Bangladesh and other developing countries considered ineffective by Western medical authorities, many drugs are also thought to be dangerous. There is indeed abundant information that the dumping of pharmaceuticals in the Third World bas caused considerable damage among their users (cf. Melrose 1982); yet this “evidence” does not convince people to reject these drugs.

7Clearly the question as to what makes pharmaceuticals so desirable cannot simply be answered by saying that some are biochemically efficacious. The whole question of efficacy is now recognized as an extremely complex one. Awareness of the “total” drug effect (Helman 1984:106) implies that several different aspects of drugs and drug-taking contribute to their impact. Discussions about the placebo effect suggest that meaning in some unspecified ways helps to heal (cf. Moerman 1983), and Etkin (1988) bas argued that efficacy is culturally constructed.

8Arguing that people want medicines only because medicines have a “natural” innate and obvious capacity to cure seems unsatisfactory. The motivation to obtain medicines is not simply that they are powerful, but that people believe them to be so. The question then returns in another form: why are people inclined to believe so strongly in the efficacy of drugs?

“Liberating” Substances

9The nature of medicines as physical substances bas important implications for social relations. In the first place, Western pharmaceuticals can be loosened from the professional territory of doctors and pharmacists. What writing and particularly printing have done to knowledge, pharmaceuticals have brought about in medicine. Writing removes the monopoly on knowledge of those who have produced it or “possess” it and makes it accessible to others. lt objectifies knowledge-that is, makes it a thing which can stand on its own, be kept in a cupboard, locked behind doors, handed over to others across place and time. Writing thus makes it possible for knowledge developed as the exclusive property of an elite to become vulgarized. Ginzburg’s (1980) case study of a 15th-century north ltalian miller, who expanded bis religious and philosophical ideas by reading books, is a striking example.

10In a similar way, pharmaceuticals objectify the healing art of physicians and make it into some-thing that can be used by anyone. Pharmaceuticals break the hegemony of professionals and enable people to help themselves. Medicines, therefore, have a “liberating” power, particularly in those societies where it is difficult to control their circulation and use.

11Alland (1970), who did research among the Abron of the Ivory Coast, was one of the first to show how medicines as substances could be divorced from relationships to experts. He pointed out that Western medicines, including the most dangerous ones, were available in local markets and shops and could be purchased without a prescription. Penicillin tablets, for example, were available in every village. He noticed that people exchanged their views and experiences with drugs, building up a fairly wide popular knowledge of pharmaceuticals. They carefully kept empty boxes, tubes, and inserts that made them familiar with the names of many drugs (1970:171). Alland remarked that what people were really after was not so much the professional help of doctors or nurses but medicines. Hospitals were seen in the first place as sources of medication, places where you might be able to get better drugs than on the open market. Thus, in Alland’s words, “the doctor often appears to be an unnecessary adjunct to the distribution of medicine” (1970:170).

13There is an even more embracing sense in which medicines may be “liberating”, and this bas to do with the relationship of the sick person to bis or ber community. Periods of illness are occasions of dependency and social control. They provide an opportunity to review social relationships and conceptions of the person in the world. In explaining and treating illness, ideas of obligation and morality are often mobilized, as countless ethnographers have shown. Family meetings, confessions, sacrifices, rituals of exorcism and collective prayer are examples oftherapy embedded in kinship and community relationships (cf. Mullings 1984). To these kinds of therapy, medicines are an alternative, a treatment that can be carried out privately and that focuses on the individual body (cf. Whyte 1988).

14Thus medicines can become vehicles of individualization, useful exactly at that point where more “relational” forms of therapy might have emphasized the person’s involvement with other people and/or subjection to spiritual forces. In many Third World societies, this potential of medicines fits with a general process of individualization associated with changing economic structures, school education, and the creation of national popular cultures.

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Medicines as Commodities

16The value of medicines seems to be based on a perception of them as having an inherent power to heal. Manufacturers ofpharmaceuticals, biomedical practitioners, and local consumers all agree on that. However, the specific meanings of a drug, the ideas about how it should be used and its specific capacities and effects, are highly variable. As things, medicines are transacted from one interpretive setting to another, retaining value but changing meaning.

18A second quality that enhances the transactability and consequently the commoditization of medicines is their small size. Medicines are easy to transport. Especially in countries with a defective transport system this quality is important. The fact that one person on foot, or traveling by bicycle or motorcycle, can carry an enormous value-amount of medicines greatly facilitates the distribution of drugs into the most remote communities. lt also makes passage from the format to the informai transaction circuit convenient and smooth. Poor medicine vendors can comfortably transport pharmaceutical products from the urban pharmacy to their village kiosk. Two types of informai distribution benefit particularly from the product’s small size: smuggling and stealing. Traders who bring medicines from Nigeria into Cameroon, for instance, have a much easier job than their colleagues who smuggle cernent. By the same token, the health care worker who takes medicine from the health center to his house can do so unseen by others.

19The value of medicines is undeniable, and this is exactly the problem from the point of view of health professionals. For them, the power of most medicines must be controlled; they should not circulate as free commodities precisely because their power may be misused wastefully or harmfully. Their exchange should be limited; there is an effort to make them “enclaved commodities” to which access is restricted (see Appadurai 1986:24). This view is based on an understanding of pharmaceuticals and health care which is esoteric. lt assumes that many medicines need a professional prescriber in order to be useful and safe. (ln this view, even “over-the-counter” medicines should be used in accordance with established guidelines.) The meaning of each pharmaceutical has to do with its biochemical properties, and fits into a complex system of knowledge about disease and the biopsychological functioning of human beings. However, the meanings which lay people attribute to medicinal commodities may be very different. Efforts to limit access to certain pharmaceuticals may merely reinforce the view that they are valuable and powerful, without bringing potential consumers to share the meanings with which biomedical professionals imbue these commodities.

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Metaphoric Associations

20Metaphors help us to grasp “reality” in an intellectual sense, to see the world in a certain way and, consequently, to communicate about that intellectual experience. Metaphors have a practical value; they help people organize their lives by providing “the semantic condition through which actors deal with” their reality (Cracker 1977:46). Femandez (1986:8) applies Burke’s definition ofproverb to metaphor: a “strategy for dealing with a situation,” but it is still not clear how metaphoric assistance works as a strategy. To explain this, Femandez resorts to a spatial metaphor. Metaphors “take their subjects and move them” (1986:12), but where? One of the most popular “movements” accomplished by metaphors in everyday life is from inchoateness to concreteness. A metaphor, like a proverb, is “a predication upon an inchoate situation. It says that something much more concrete and graspable-a rolling stone, a bird in the hand-is equivalent to the essential elements in another situation we have difficulty in grasping” (Femandez 1986:8).

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21So far we have argued that the metaphorization of illness, making illness a concrete and “natural” phenomenon, provides a favorable context for the use of medicines. But that paints too passive a picture of the role of medicines. Metaphors for illness assume a teleological character; they “know” where they are going. Their direction is the taking of medicines. One could say that the existence of therapeutic substances invites the concretization of ill-being, or that the metaphoric objectifying of illness fulfills the expectations of medicines. Black (1962:37) writes that in some cases, “it would be more illuminating to say that the metaphor creates the similarity than to say that it formulates some similarity antecedently existing.” Defining illness in a way that makes treatment possible (e.g., prescribing medicines, but also surgery, radiation, rest, etc.) is exactly what we have earlier called-in Burke’s words – “a strategy for dealing with a situation.” That is the “mission of metaphor” (Femandez 1986:28-70).

22The notion of illness as an entity within the body is widely found. The ethnographie literature suggests that people in many cultures live by this metaphor, using emetics, purgatives, sweat baths, and cupping homs to remove the sickness from the body. Our point is that the treatment calls for the conception as much as the conception calls for the treatment. Pellegrino, referring to Sigerist, points out the extremely common supposition that sickness arises from intrusion of “something” into the body or loss/damage of some vital substance. Both conceptions fit with medicines: “The act of prescribing satisfies a complex urge of ancient lineage which predisposes humans to combat disease by taking in a chemical agent, which either drives out the intruding cause or replaces the ‘something’ lost in illness” (Pellegrino 1976:625). But it also applies the other way round. Doctors use medicines to diagnose: “If Flagyl works, it must be amoeba!” Sickness and medicine, entity and counter-entity motivate one another.

23The metaphoric movements of medicines in relation to psychiatrie conditions are particularly revealing, because such conditions are especially difficult to communicate. Rhodes (1984) describes how psychotropic drugs are said to “clear the mind,” “to straighten one’s thoughts,” or “to keep one’s thoughts together.” But for Rhodes, describing the metaphoric concreteness of the action of drugs is only a stepping stone to a more general conclusion: drugs are themselves strategies of concretization. They are “facilitators” for establishing meaning and for communication. What Lévi-Strauss (1963) said about animais and plants in bis essay on totemism applies to drugs in a psychiatrie setting: they are “easy to signify” (1963:60), “their perceptible reality permits the embodiment of ideas and relations conceived by speculative thought on the basis of empirical observations” (1963:89). Thus, communication about medication becomes communication about problematic and ambiguous experiences.

24In an article about communication and medicines in a rural clinic in Sri Lanka, Sachs (1989) develops an interesting twist on this issue. She suggests that medicines bridge the gap in understanding that exists between doctor and patient. The concreteness of drugs provides a focus for each party in their conceptualization of the problem and at the same time overshadows the fact that they mean quite different things to each.

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25ln metonymic speaking, as in metaphoric, one entity is used to refer to another one; that reference is not based on similarity, however, but on some type of connection. Lakoff and Johnson (1980:38-39) mention the following types: partwhole, producer-product, object-user, controller-controlled, institution-people in the institution, place-institution, place-event. Many more could be added to these. Metonymic references have an effect that is very similar to that of metaphors: concretization, either by putting a phenomenon more firmly in the natural or physical world (e.g. part for whole and place for event) or by linking it to a causal agent (e.g. producer for product). Lakoff and Johnson explain:

Metonymic concepts structure not just our language but our thoughts, attitudes and actions. And, like metaphoric concepts, metonymic concepts are grounded in our experience. In fact, the groundings of metonymic concepts is in general more obvious than is the case with metaphoric concepts, since it usually involves direct physical or causal associations. The part for whole metonymy, for example, emerges from our experiences with the way parts in general are related to wholes. Producer for product is based on the causal (and typically physical) relationship between a producer and his product. The place for the event is grounded in our experience with the physical location of events. And so on. [1980:39]

Locating Illness

26There are two closely related metonymic processes that are of great significance for making illness concrete and facilitating the use of medicines. These are part for whole and localization. Locating a health problem in some part of the body bas mainly two effects: it makes the complaint more specific and allows for directed action. Locating the complaint in a part does not deny the suffering of the whole body or the whole person. The implied causal ordering of the metonym is that the illness of the (whole) person is brought about by the dysfunctioning of one body-part, as is also suggested by the Biblical saying, “If one member suffers, all suffer together” (1 Corinthians 12:26). The opposite view, that a person’s suffering "settles down" in a particular part of the body, is less prominent in Western popular thinking.

27Locating the complaint is, as it were, providing a geographical map for therapeutic intervention. Medicines, as we have seen, are believed to work in a very concrete manner. They change the physical composition or restore the mechanics of a body part. They can be applied locally or sent to the troubled area through the canais of the metabolic and arterial systems. The localizing metonym shows the way for medicines to be taken.

Producer and Product

28In speaking about the metaphoric concretization of illness, we discussed only one style of concretization, likening illness to natural, physical phenomena. This type of metaphor dominates in the biomedical tradition and in many other medical cultures. Another common style of explaining and dealing with illness is, however, “personalization.” Negative experiences can be made concrete and tractable by seeing them as conditions that have been purposely brought about by the actions of willful agents, either human or non-human, person-like beings (Foster 1976). In this producer-for-product kind of connection the product, illness, is linked to a producer, the agent. Attributing illness to a certain person is transporting the elusive experience to the concrete world of social relationships where power, knowledge, and specialized techiques of others can be marshaled to solve the problem. In this personalized world of illness explanation, the counter-agent, the healing expert, assumes a prominent place. Here we want to argue that medicines are metonyms in that they are treated as physical representations of a larger context of which they are part.

29Personal relations can be crucial in that context. As we have seen, medicines “liberate” the patient from the bands of doctors and other therapeutic specialists. The doctor may control the situation in which the medicines are dispensed or prescribed. He may add certain words of reassurance and instruction. All this is part of the treatment. But the patient can take the medicine home, use it for awhile, keep it in ber medicine cabinet for a year, and then give it to a neighbor who suffers from the same problem she used to have. This kind of separation of one concrete element from a total context of healing is not possible with other reifying forms of treatment administered by practitioners. One cannot separate surgery from the skill of the surgeon, nor acupuncture from the acupuncturist, nor massage from the masseur.

30However, the attraction ofthis capacity for separation and conveyance from one therapeutic context to another is not simply that people can take medicines without consulting a doctor. One of the “charms” of medicines is that, even removed from their medical context, they retain a potential connection to it. The medicines have a metonymic association with medical doctors who prescribe them, with laboratories that produce them, with medical science that forms their ultimate ground. Through medicines people enjoy the fruits of medical expertise without the inconvenience of actually having to go to the doctor. Montagne (1988:421), quoting Pellegrino (1976), writes that medicine is "the visible sign of the physician’s power to heal, and in contemporary society, is a symbol of the power of modem technology.

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31One question seems to us of central concern for further study: how does the use of Western pharmaceuticals fit with changes in the social relations of healing? We have mentioned the way in which medicines facilitate self-treatment and thus remove therapy from the social relations in which it would otherwise be embedded. In speaking of this as “liberation,” we have not meant to cast a value judgment on the process. ln the back of our minds was the sense in which Marx spoke of peasants being “liberated” from feudal relations, so that their labor power might be available on the market. ln the same way, people “liberated” from relations to doctors, senior relatives, or spirit exorcists, become dependent on less persona! market relations in order to obtain medicines. In this process, new kinds of relations may be formed as well-to drug vendors, local injectionists, or shopkeepers who provide advice to the buyers of medicines.

32A related aspect which we have not dealt with here is the possibility that it is the weakness of the social relations of healing which motivates the interest in medicines. Failures of health delivery systems and poverty which does not permit people to enter into relations with professionals may be factors that push people toward self-help.