The tyranny of empty shelves: Scarcity and the political manufacture of antiretroviral stock‐outs in South Kivu, the Democratic Republic of the Congo

Abstract

At the margins of the global scale-up of antiretroviral treatment for HIV, the Democratic Republic of the Congo has experienced severe regional stock-outs of essential medicines. Usually framed by global health actors as signs of technical, logistical, and professional deficiency, antiretroviral scarcity is -perhaps surprisingly -rarely considered to be an exceptional event. Attention to the local consequences of scarcity in the east of the country, however, suggests that stock-outs arise from far more than mere infrastructural failings. Drawing on an investigative ethnography conducted in the province of South Kivu between 2016 and 2018, this paper examines how stock-outs in the region have political functions rooted in the calculated denial of medicine to geopolitically significant communities and individuals. Informed by extant research the geopolitics of health, I begin by conceptually framing the geographical significance of stock-outs and locate in their origins and functions the discriminate use of scarcity as a biopolitical tool. Then, drawing on interviews and the analysis of previously unpublished and uncollated stock records, I demonstrate the technical and political origins of stock-outs at six dispensaries in the province. The supply of essential medicines, I argue, has become weaponised and their denial represents a strategic gambit for armed actors seeking territorial footholds in the region. Focusing on the cases of two out-of-stock towns in the south of the province, I then examine patients' agonising experiences of stock-outs, the poisoning and distortion of local moral economies that scarcity gives rise to, and the profoundly ambiguous transformations of therapeutic citizenship birthed by denial of treatment. I conclude by returning to the scale-up of antiretroviral treatment and review the critical avenues opened up for health geographers by a focus on the provisioning, scarcity, and denial of essential medicines.

Contextualising coronavirus geographically

“…Across all of these, a concern with the factors shaping varied local experiences and embodiments of disease represents an enduring contribution of geographical research. Just as in global health geography more generally, it will be critical to examine in this way what gets to count as representable "local" experience, in whose "local" bodies, all the while other spaces of exception and biological sub-citizenship go ignored, uncounted or devalued (Brown et al, 2012;Herrick, 2014;Hirsch, 2019;Ingram, 2010;Laurie, 2015;Neely & Nading, 2017;Pallister-Wilkins, 2016;Patchin, 2020;Sparke, 2017a;Taylor, 2019). But to contextualize the coronavirus crisis further, we can also point to (1) geographical work on the emergence of infection, along with research that helps explain the uneven geographies of (2) vulnerability, (3) resilience, (4) blame, (5) immunisation, (6) interdependence and (7) care exposed by the pandemic.…”

The US military's malaria research in Kenya and the geopolitics of global health

“…The paper reveals the attachments to war (Terry, 2017) that underpin the military's global health engagement practices and that permeate mainstream global health networks and sites of health intervention. Beyond the specifics of the Walter Reed Project, the paper points to the trends of military involvement in global health, with militaries leveraging the sanitised framing of global health (Taylor, 2020) to further geopolitical ambitions. These trends reveal an underexplored dimension of state power in global health contexts, the ways the possibility of war can be enabled through medical research that is ostensibly carried out to benefit global health, and highlight the implications of the increasing normalisation of the military's presence in contexts “beyond the battlefield.” For instance, in popular representations of military‐supported medical developments, such as the RTS,S/AS01 vaccine (Davies, 2021), the military's central role is often overlooked and rarely scrutinised.…”

“…Not only does this framing obscure the individual and collective identities of those subjected to medical research and surveillance, but it also reduces them to biological elements that are drawn on as a resource that supports US war‐making, both entangling geopolitics and biopolitics (Braun, 2007) and echoing earlier practices of colonial medical intervention. There is already an inherent uneven power relationship at the root of medical humanitarian practices (Fassin, 2012; Taylor, 2020). But the Walter Reed Project's involvement in global health research casts the basic biological material of local communities, accessed in the sanitised name of global health, as a geopolitical resource that may support US armed forces' health and enable the conditions for war‐making elsewhere.…”

“…First, the paper demonstrates the US military's capacity to bring US national security motivations and geopolitical logics to bear on global health research agendas. As Stephen Taylor (2020) has shown, the sanitised veneer that surrounds global health conceals its politics and its intrinsic inequalities. As a series of health organisations, research institutes, philanthro-capital organisations, and pharmaceutical companies that coalesced under neoliberal globalisation (Bashford, 2006;Kenny, 2015;Reid-Henry, 2016), mainstream global health is founded on, and perpetuates, uneven power relations between the global north and the global south (Kelly & Beisel, 2011;Prince, 2013).…”

Unbracketing the multiplicity of trauma in North Kivu, Democratic Republic of Congo

“…The national healthcare system is poorly equipped to respond to these complex and protracted emergencies with, for example, only 6 public mental health hospitals (with a combined 500 beds) in a country of 68 million people (Taylor, 2017). Access to essential medical supplies is irregular and rarely sufficient to meet complex needs (Taylor, 2020).…”