Book Review: Aids Drugs for All: Social Movements and Market Transformations, by Ethan B Kapstein and Joshua W Busby

February 23, 2018

     By Duncan Green     

Thanks to Chris Roche for sending me back to re-read this wonderful case study of how activists can change markets (here’s a free pdf of the first chapter). Kapstein and Busby painstakingly researched the rise, tactics and successes/failures of the global advocacy campaign around access to medicines for HIV/AIDS. Their (hugely ambitious) aim is not just to understand a movement that has saved thousands of lives, but to draw wider lessons because, as they say: ‘recent years have seen an explosion in the number of advocacy campaigns aimed at changing the behaviour of multinational corporations and the way that markets function’. (Think fair trade, fisheries protection, labour standards, carbon emissions, land grabs, gender equity.)

Besides the case study, the authors delve into the academic literature on the economics and politics of markets (great quote from Carlyle: ‘teach a parrot the terms ‘supply and demand’ and you’ve got an economist’), which means it gets pretty dense in places. But the book is a treasure trove of insights and advice – highly recommended. It’s also bloody hard to review – there’s just too much there.

So I’m going to do violence to the book and jump straight to its Big Idea on the role of advocates in spurring transformations, which the authors call a ‘theory of strategic moral action’:

‘Market transformation in the case of Anti Retrovirals required the following: first, a market structure or favourable set of underlying economic and industrial conditions that provided opportunities or openings for an advocacy movement; second the elaboration by the AIDS movement of a compelling frame that pitted drug company profits against global access to life-saving ARV medications; third, a political and organizational consensus or coherent ‘ask’ on the part of the social movement that treatment should receive the highest policy priority, trumping, for example, prevention; fourth, a feasible strategy (defined in this case as one that minimized the costs of market transformation to the major players)  for how a universal access to treatment market could be made to operation; and finally, a set of institutional arrangements to help set the rules for the transformed market and to stabilize its operations.’

Their conclusion becomes a handy checklist/steer for other activists, with a chapter on each fleshing out the issues:

‘Advocates need to ask whether they have identified the opportunities within the industry they are targeting; whether they have framed the issue in a compelling way; whether they have a coherent ask; whether they have a feasible strategy that addresses concerns about costs by firms and governments; and whether supporting institutions need to be built.’

Along the way they show a nuanced grasp of systems – the shifting tides of institutions and markets, noting that the regime around intellectual property was still emerging, and so malleable than older, more fixed arrangements, and that the pharmaceutical industries’ degree of turbulence (lots of disruptive mergers and acquisitions) and concentration made it easier for activists to play divide and rule between the big companies.

Next up they apply their theory to a bunch of other global campaigns seeking to emulate the impact of AIDS activists: malaria, maternal mortality, diarrhoeal disease, non-communicable disease (heart, cancer, diabetes), education, climate change, the elephant ivory trade, sex trafficking, and then they even back test their theory against the abolition of the Atlantic slave trade. Only access to malaria treatment achieves a ‘likely’, while reducing maternal mortality, expanding access to treatment for NCDs, reducing ivory poaching and sex trafficking get a ‘mixed’ and reducing deaths from diarrhoea, improved education, curbing climate change all get an ‘unlikely’. Activists shouldn’t get too downcast though – even abolishing the slave trade only gets a ‘mixed’……

But the guidance on questions to ask is, I think, really helpful, forcing activists to think more broadly about systems, opportunities and dead ends. It offers some useful advice on when not to campaign, by urging them to consider ‘where movements are placed in terms of their ‘life cycle’. If the market structure is difficult to contest (eg because of excessive fragmentation), movements may never really gain traction. Even with a compelling frame, unless movements cohere around a common ask, they will have difficulty convincing target actors to listen to them. Even where they are able to overcome this obstacle, they may face an uphill battle if the costs of their ‘ask’ are too high. Finally, in the absence of institutions that help stabilize the market around a new principle, the commitments may not endure – a movement may fracture and backslide to an earlier stage.’

That last point is particularly challenging, I think. It’s not enough to win, you have to think institutionally about what will make your victory sustainable. That’s a lot to ask of often small, under-resourced activist organizations.

I did have a few misgivings. Hindsight is a wonderful thing, but also creates a misleading sense of clarity andinevitability, transforming the fog and serendipity of events into a nice linear history. Typically, such accounts downplay the role of accident, luck. And having stupid opponents.  That was vital in the access to medicines case, where some collective madness persuaded Big Pharma in 1998 to sue the South African government over its efforts to get cheap medicines to the sick. That’s right, they took Nelson Mandela to court, handing activists a perfect ‘Problem, Solution, Villain’ campaign moment. They dropped the case 3 years later, but by then the damage was done and the global AIDS movement never looked back.

And here’s a flavour of the South Africa campaign – Treatment Action Campaign: the First Five Years