It is surely one of the paradoxes of medical anthropology that the industrial expansion of Asian medicines—a phenomenon of global scale and relevance by any measure—has coincided with a diminishing academic interest in Asian medicines, as the discipline at large has shifted its focus to mainly biomedical topics during the recent decades (Scherz 2018). Yet while research on Asian medicines may not have increased in quantity, it has certainly gained in quality, with a steady stream of important publications carrying forward—and, crucially, rethinking—Charles Leslie’s field-defining legacy (Leslie 1976). Céline Coderey and Laurent Pordié’s Circulation and Governance of Asian Medicine, the product of a multidisciplinary workshop in September 2015 at the Asia Research Institute of the National University of Singapore, is the latest appearance in this venerable line of edited volumes. It identifies circulation and governance as the two central practices that today shape and transform industrial Asian medicines, and explores their relationship with the aim of revealing the fluid and multiple nature of Asian medicines as mobile commodities.
Like many of its predecessors (e.g., Alter 2005; Connor and Samuel 2001; Ernst 2002), Circulation and Governance does not revolutionize the field as much as it incrementally advances it. It does so by updating and combining three of the most important strands of inquiry in recent research on Asian medicines. First and most fundamental, it participates in the ongoing reframing of Asian medicines as industries (e.g., Kloos 2017; Kloos et al. 2019; Pordié and Gaudillière 2014a; Pordié and Hardon 2015) rather than as cultural or epistemic systems, adding substantial material and weight to this approach. Second, the volume provides a crucial and so far not sufficiently developed dimension to research on Asian medicines’ regulation regimes (e.g., Adams 2002; Craig 2011; Saxer 2012), namely, their reciprocal relationship with the circulation of herbal pharmaceutical products. Indeed, the book’s key point is precisely that neither the governance nor the circulation of Asian medicines can be understood in isolation from the other. Third, the topic of circulation directly connects to previous work on globalization, most notably Joseph Alter’s edited volume Asian Medicine and Globalization (Alter 2005). Yet where Alter and his contributors focused on flows of knowledge and the tension between nationalism and transnationalism, and framed their inquiry in terms of culture, this volume deals mostly with pharmaceutical objects and the mutual relationship of governance and circulation, and situates its analytic in the domains of policies and the market.
Circulation and Governance consists of an introduction, seven chapters, and a short afterword, moving in emphasis from governance (chaps. 1–4) to circulation (chap. 5–7), and from diachronic analyses (chaps. 1–5) to synchronic ones (chap. 6–7). The introduction situates the book’s topic within a limited selection of literature on Asian medicines, but does justice neither to the state of the art of research, nor to the chapters that follow. Thus, the statement that Asian pharmaceuticals and their regulation should be considered as assemblages might have productively engaged with the “pharmaceutical assemblage” (Kloos 2017); the discussion of state power and biopower could have benefitted from recent work on Asian medicines’ recognition and integration into national health systems (e.g., Blaikie 2016, 2019; Lei 2014); and the framing of pharmaceutical regulation as inherently antagonistic to Asian medicines may have been reconsidered in light of recent studies (including the chapters in this volume) suggesting a more complex picture (e.g., Cuomu forthcoming; Kloos et al. 2019; Saxer 2012). The domain of intellectual property—crucial to both circulation and regulation of Asian medicines—is hardly mentioned at all (e.g., Cullet and Raja 2004; Gaudillière 2014; Madhavan 2017; Pordié 2008).
Similarly, the identification of cross-cutting themes does little justice to the comparative and synergetic potential of the chapters. While the theme of biomedical governance is obvious but hardly new, “the power of invisible ingredients” appears as a tangent in a single chapter (chap. 3), but nowhere else. That “the economy” plays a role in the governance and circulation of Asian medicines is clear, but defining it as a “monolithic and homogenizing form of capitalism” brought about by globalization (13) flies in the face of both ethnographic reality and critical anthropology of capitalism (e.g., Tsing 2015). “Governing categories” of Asian medicines, such as drugs, supplements, or foods, are indeed an important recurring theme throughout this book, and indicate the blurring of boundaries so characteristic of Asian medical industries. Final and perhaps most surprising, the introduction frames circulation and governance as structural opposites, the former flowing across boundaries, the latter creating and enforcing them (17). Superficially, this may be true enough, but the volume actually tells a deeper, much more interesting story of coproduction and interdependence, as coeditor Pordié remarks in the afterword (157).
Karen McNamara’s chapter 1 offers useful insights into the regulation of Ayurveda and Unani in Bangladesh. Tracing their integration into the country’s official infrastructure from the early 1980s until the 2010s, the chapter particularly focuses on two key documents: the 1982 Bangladesh Drugs Control Ordinance, which legally recognized traditional medicines by creating an official category for them; and the new National Drug Policy of 2005, which introduced herbal medicines as a new category. McNamara argues that the legal status and regulation of Asian medicines, as illustrated by both documents, directly respond not only to the domestic context but crucially also to global health, trade, and intellectual property regimes (WHO in 1982, the WTO and TRIPS in 2005). Thus, the 2005 legislation was based on the global circulation of herbal medicines rather than an (at that time nonexistent) export-oriented industry in Bangladesh itself.
Eunjeong Ma’s chapter 2 traces the Baekshuoh “disaster” to highlight the difficulties in applying modern scientific safety regulations to Asian medicines, even in a highly developed and regulated context like South Korea. The case revolves around the EstroG-100 compound, marketed as a “functional food” for menopausal symptoms, the main ingredient of which was illegally substituted with a related species. While almost identical in appearance, the latter was found unsafe for consumption and not listed in the Korea Herbal Pharmacopoeia, but was a more profitable crop than the former. The availability and profitability of raw materials thus directly undermined the safety regulations of herbal products. Ma uses this case as a critique of state-enforced commercialization of “traditional medicines” into modern health products (she calls this “coerced medical/pharmaceutical bilingualism”), but it equally serves as a poignant reminder of the central but often overlooked role of raw materials in Asian medical industries (see also chap. 6).
Céline Coderey’s chapter 3 provides rare insights into traditional medicine in Myanmar and the tensions between their regional/ethnic diversity and state efforts to institutionalize a single “national medicine.” Similar to McNamara, she traces the institutionalization of traditional medicine from the late 1960s, revealing this to be a “valorization project” where global forms (e.g., WHO policies) were used to construct an ethnically Burmese, Buddhist medicine at the expense of minority ethnic and religious groups. Despite its ostensive distinction to Western medicine, however, this “national medicine” was biomedically conceived and governed. Coderey argues that while such standardization, predicated on the politics of nation building and the logic of biomedicine, was partially successful in homogenizing the form of Burmese traditional medicine, its circulation actually depends on their diversity in content and affiliation. Thus, regional identities serve as unique selling points on the market, and a weak regulatory system enables producers to use different ingredients in officially standardized formulas.
Arielle Smith’s chapter 4 on the regulation of Chinese medicine in Singapore connects well with the previous three contributions. It situates the trajectory of Chinese medicine’s status in Singapore in a context of colonial and postcolonial biopower and governmentality: tolerated by the British and shunned after independence as a Chinese cultural practice, Chinese medicine began to be legitimized and regulated more recently under the authority of biomedicine. Yet as national delimitations of Asian medicines are increasingly destabilized by transnational trade, it is other actors than the state (e.g., producers, importers, transnational organizations) who now have an interest in their regulation. Scientific quality controls remain inadequate for the task and are therefore much less widely implemented than traditional quality control methods. Smith’s argument that Chinese medicine is redefined and transformed in response to global circulation is important, yet a more interesting point here lies in the observation that regulation is less an obstacle than a prerequisite for circulation in modern transnational contexts.
Liz Chee’s chapter 5 traces the history of fish liver oil eastward from the US to the UK and finally to China, in a concise but excellent exploration of the boundaries between food and drugs. Since the US 1906 Pure Food and Drug Act, which stipulated a strict separation of foods and drugs, up to the more recent emergence of health products, functional foods, and dietary supplements, the classification and regulation of such substances have played a central role in the development and circulation of Asian medicines (as already shown in previous chapters). Chee argues that such classifications are determined not so much by science than by political economy, as tariffs, health insurance schemes, war strategies, and economic policies led to changing classifications (from patent medicine to food supplement to health product)—and even contents—of fish liver oil. At the same time, she shows clearly how regulation and circulation coproduce and mutually depend on each other. In a neoliberal global trade environment, the chapter concludes, the category of health products proves exceptionally profitable precisely because they blur the lines between food and medicine, thereby partially evading national regulatory regimes.
Caroline Meier zu Biesen’s chapter 6, as also (indirectly) chapter 2, pays welcome attention to the topic of ingredients and raw materials—in this case, Artemisia annua. Originally part of Chinese medicine’s materia medica, its extract is today used in artemisinin-based combination therapies (ACTs) used as first-line treatment for malaria. The chapter outlines a fascinating trajectory from Chinese plant and communist research to African commercial commodity and, finally, the patented Novartis ACT drug Coartem, exploring the entanglements between WHO policies (esp. its classification of Coartem as an “essential medicine”), national governance, and local health and economies in Tanzania. While critiquing the often problematic humanitarian, medical, and economic consequences of global and national health policies, Meier zu Biesen argues that it is precisely international regulations that transform plants into commodities and Asian medical knowledge into global pharmaceuticals. Governance, once again, appears as directly connected with circulation.
Simeng Wang’s chapter 7, finally, makes an important contribution to the book in emphasizing that transnational circulation not only functions through formal regulation and official rules but also through illegal practices and circumvention strategies. Taking the example of Chinese medicine, Wang shows how its circulation between China and France has been accomplished by evading strict regulations, and how this circulation in turn shapes the regulatory framework. Through professional networks, illegal practitioners and traders learn circumvention strategies like changing the product category from drug to “functional food,” geographical mobility, or calling on international norms and collaborations. The chapter argues that while reacting to national and international rules, these strategies—together with active lobbying by practitioners, professional associations, and states (in this case, China)—also influence these regulatory regimes. The result are highly complex itineraries of circulation and frameworks of regulation standards.
Given coeditor Laurent Pordié’s expertise and previous groundbreaking work on the topic (e.g., Pordié and Gaudillière 2014b), it is a pity that this book does not include a chapter by him. In a short afterword, however, Pordié summarizes and discusses the volume’s main argument about the reciprocal relationship, and indeed coproduction, of circulation and governance. Pointing out that circulation is largely industry led and anchored in national and global markets, while governance mainly happens in the policy sphere and is dominated by public institutions, he argues that both have the potential to transform pharmaceutical objects. Going further, he points out that regulatory regimes not only fulfill political purposes such as nation building but also have a moral character in the sense of imposing new behaviors, values, and notions of right and wrong. In a return to classical anthropological themes like culture, power, and religion, Pordié suggests that the book’s subliminal message might be a call for expanding the concept of governance in Asian medicines to include “systems of control and regulation that go beyond the realm of institutional governance and practice” (160).
One of the strengths of Circulation and Governance lies in the focus and coherence of its chapters: without so much as a single chapter that does not directly address the book’s general topic, and a consistently high level of quality across all chapters, this tightly curated volume provides rich insights and material for comparison. This is all the more true as it includes, besides the usual suspects of Chinese and Ayurvedic medicines, research on otherwise underrepresented countries like Bangladesh, Myanmar, and Singapore, and objects that do not neatly fall into the category of “traditional Asian medicine,” such as fish liver oil or the artemisinin-based biomedical drug Coartem. Unfortunately, the good work of the editors stands in sharp contrast with an insufficient review, language editing, and copyediting process on the part of the publisher (Routledge), which is particularly evident in the introduction. Thus, easily avoidable language issues (e.g., “Jane” instead of “Janes” on page 1, “worldling” instead of “worlding” on page 10, or “outbreak” instead of “outcry” on page 49) as well as errors in content (e.g., page 10: Adams 2001 and 2002 deal with Tibet, not India; page 12: Tibetan precious pills are not a “multibillion-” but a multimillion-dollar business in China) distract from the otherwise mostly excellent scholarship.
Everything considered, this volume is an important contribution to the medical anthropology and social sciences of Asian medicines. Despite the growing relevance and size of Asian health industries worldwide, critical research that directly explores the topic remains rare, and the editors deserve kudos for assembling such a fresh and diverse generation of high-quality scholarship—by no means an easy task. As a reader, a fairly good understanding of contemporary Asian medicines and a willingness to analytically work with and across the different contributions is helpful to appreciate the full potential of this book, although the individual chapters can stand alone, too. Circulation and Governance is thus most suitable for graduate students, scholars, and interested professionals of Asian medicines. There is no doubt that this book will be widely read within the field of Asian medicine studies and serve as a key reference for a long time to come.