Pharmaceutical surveillance, medical research, and biovalue among the urban poor

This dissertation is an exploration of the ways in which therapeutic interventions and medical research surrounding HIV/AIDS are co-constitutive in Vancouver’s impoverished inner-city community. It explores the ethical implications for medical research, epidemiological surveillance, and ethnography in the late-capitalist, twenty-first-century Canadian context. I combine elements of an ethnography of clinical care – including extensive naturalistic-observation at urban medical clinics that provide HIV treatment and interviews with clinicians, health administrators, people living with HIV, and scientists - with a reading of epidemiological literature pertaining to HIV-positive people living in Vancouver’s inner city. In which ways is the production of medico-scientific knowledge related to the distribution of pharmaceuticals for HIV in Vancouver’s inner city? Here, I examine (1) the state-sponsored public health programs that have been created to improve compliance through the use of directly observed therapy, (2) the epidemiological discourse on adherence, (3) the relationship between pharmaceuticals and treatment, and (4) the contestation of therapeutic guidelines in the clinic. Informed by the writings of Michel Foucault, I situate my analysis within larger debates surrounding postcolonial medicine, disparities in access to treatment, and the global politics of HIV/AIDS research. I reflect on the ways in which inner-city populations are regulated and monitored through both illicit and licit pharmaceuticals. I suggest that citizens whose lives are characterized by poverty, suffering, and abandonment in the Canadian state, who are perceived as “valueless”, have become critical commodities in the combined therapeutic and research economies, where they are valued for their suffering, disease, and bodies. Drawing on the work of Nikolas Rose, I suggest that, in the inner city, a lack of vitality constitutes a source of biovalue. The AIDS virus itself is a productive force, and becomes valued, through creating the imperative for vaccines, pharmaceuticals, and epidemiological surveillance. For epidemiologists and other medical researchers, the virus and its effects, along with the results of interactions between the pharmaceuticals and the disease (e.g., drug-resistant viruses), are productive sources of new scientific knowledge and new subjectivities. Finally, I reflect on the implications of this for conducting ethical critical ethnographic research on biomedicine.