Discourses, coalitions, and durable identities : narratives of lawmaking and regulation of clinical trials in Costa Rica

"For over four decades, Costa Rica was an increasingly attractive location for clinical research sponsored by foreign governments and multinational pharmaceutical companies. However, in 2010 the Constitutional Court handed down a decision to suspend interventional medical research which resulted in the loss of over 200 jobs and a professional brain drain, as physician-researchers and their teams either left the country or sought new employment. Over the years two opposing advocacy coalitions, whom I call the Statists and the Neoliberal Entrepreneurs, engaged in strategic use of the media to reinforce their policy perspectives and core beliefs about whether and how clinical research should be regulated within Costa Rica. This dissertation examines these narratives and discusses how this discourse led to the coalescence of two distinct advocacy coalitions with a membership of elite leaders in academia, the public health system, the government, and private research facilities. The decades-long reiteration of these narratives about clinical research and the role of foreign investment led to each coalition developing a cast of characters, explicitly identifying the heroes, the villains, and the victims of these stories. The analysis of these narratives and coalitions extends three areas of anthropological work. Critical medical anthropology addresses the ways a small country confronts globalization through laws and regulations. The anthropology of public policy allows for the exploration of policies and policymakers (both formal and informal) as problem spaces to be examined. Finally, this dissertation illustrates the role of narratives (stories) that are used to enact and influence change and how the media becomes a vehicle for the transmission of elite discourses. The central question of this research asks how the lawmaking process impacted the livelihoods and social capital of those in and around the clinical research industry in Costa Rica. Three specific aims have guided my research. To do this, I explore the public debate regarding clinical research in Costa Rica as presented in news articles and opinion pieces. Secondly, I examine the changes in the livelihoods of healthcare and research professionals, support staff, and other stakeholders due to the 2010 Constitutional Court decision to suspend new biomedical research. Finally, I analyze the advocacy coalition strategy of policy narratives used by coalitions for and against clinical research inside the country and the effects these strategies had on identity, both in each's coalition identity and for individuals within each coalition. This dissertation research utilizes ethnographic methods, narrative analysis and a qualitative use of the Narrative Policy Framework as presented by Gray and Jones (2016) to traces the growth of these two local coalitions and their strategies for changing policy to regulate clinical research in the country. Employing a qualitative approach to the Narrative Policy Framework often used in public policy analysis highlights the ways in which consistent policy narratives shape coalition beliefs and the durable identities of both the coalitions and the individuals within each coalition. In this dissertation, I have provided evidence of how elites in Costa Rica used the stylistic quality of argumentation through opinion pieces to secure their social position, entrench their perspectives on clinical research in the country as well as to reify Costa Rica's exceptionalism according to each advocacy coalition's definition."--Pages ii-iii.