\n<\/p>\n
Why should the figure of the middleman matter for scholars of global health? The short answer is: they are impossible to avoid. The long answer is as follows:<\/p>\n
Throughout the twenty-first century, claims have circulated that the global pharmaceutical supply chain is awash with fakes, and these claims sparked our curiosity. For nearly a decade, we have been studying such claims and, in particular, their effects on how people understand themselves and their health. In short, we have asked: what\u2019s at stake in the fake? (https:\/\/www.fakedrugsproject.org\/<\/a>; Bandora 2023; Calkin 2024; Goodman 2024; Hodges 2024, 2019; Hodges and Garnett 2020; Hodges and Hornberger 2023; Hornberger 2024, 2019, 2018; Hornberger and Hodges 2023, 2024; Hornberger; Hodges, and Chitukutuku 2023; Kufakurinani 2022, 2024; Peete 2023; Rodrigues 2024; Sirrs 2023; Thakur 2023).\u00a0<\/p>\n In our research into \u2018fakes\u2019 within global health, one figure kept popping up: the middleman. These were women and men often with little formal expertise, understated and yet confidently managing matters of health, inserting themselves deliberately at one of many key intersections through which people, goods, and ideas flow. Once we started paying attention to them, our field sites all situated in and related the field of global health suddenly became thick with middlemen and middle-women[1]<\/a>: people who bought and sold pharmaceuticals, those who ran health care labour recruiting agencies, street theatre audiences commenting on a health education play, diasporic travellers freighted with both care work and curative goods, and even an international taskforce brokering health treaties between unlikely actors.<\/p>\n Yet, middlemen \u2013 both the people and the category \u2013 presented a puzzle to us because the people whom we encountered in our research did not match what journalists or health policy scholars had warningly written about them, in pieces like: <\/a>\u2018It is time to surgically remove the middleman<\/a>\u2019 (Brock 2022) or \u2018At the pharmers market patients suffer while middlemen profit\u2019<\/a> (Pipes 2022).\u00a0 In such accounts, the middleman was a mere culprit, a redundant if not parasitic figure, invoked as a kind of shorthand to explain the persistence of so-called fake drugs.<\/p>\n Health policy scholars and commentators have mostly cast middlemen as vilified profit-seekers who corrupt health interventions. Occasionally, middlemen appear not as villains but as accidental heroes who fill urgent gaps in the delivery of essential services (Dalstrom 2013; Elbe, Vorl\u00ed\u010dek, and Brenner 2023). In all these accounts, however, whether heroes or villains, \u2018middlemen\u2019 were invoked as part of a broader moral landscape. It appeared that in the high moral stakes that suffuse the field of global public health, middlemen can almost only logically exist as a morally overdetermined caricature and is hardly ever given the time of day to be described or analysed in terms of their actual actions. The middlemen we found, in contrast, were real, complex characters, sitting in plain view and conducting the everyday business of global health. They unabashedly looked after their own interests and yet they seemed to play an important role in keeping the rickety show of global health on the road. What were we to make of this mismatch between what experts have said about \u2018the middlemen\u2019 in global health and what we found?<\/p>\n Once we rowed out from the discursive shores of global health, many more middlemen came into scholarly view. Anthropologists and sociologists have long recognised the significance of brokers, agents, and fixers (e.g. Bjorkman 2021; James 2011; Platt, Raj, and Kardia 2019; Hunter 2020) while political scientists have their own preoccupations with brokers in party politics and property transactions (Sud 2014; Thachil and Auerbach 2018; Auerbach and Thachil 2020). Like Bjorkman (2021), we found that the strong moral charge surrounding middlemen complicated our capacity to analyse them. We also wrestled with a conceptual challenge: how to define \u201cmiddlemen-ing\u201d when neither a distinct activity nor a stable identity could capture what they do. Middlemen delivered a vast array of services, yet these services were as varied as the middlemen themselves.<\/p>\n This left us with a puzzle: how could we engage with middlemen as an expansive category without sacrificing the analytical precision our inquiry required? We chose to double down on the one feature that consistently cut across all our cases: their position between two or more poles or parties. In other words, we selected their in\u2011betweenness<\/em>\u2014their relationality\u2014as our analytic lens.<\/p>\n In this task, we turned to earlier sociocultural theorists who outlined the basic elements of who middlemen are and what middlemen do. We draw particularly on Sidney Mintz\u2019s \u2018higgler\u2019 (1956), Georg Simmel\u2019s (1908) \u2018stranger\u2019, and Clifford Geertz\u2019s ([1979] 2022) accounts of those who populate the suq<\/em>. Eschewing normative definitions of middlemen, these scholars focused on how middlemen performed structural work and held relational power. Importantly, this body of work showed how middlemen\u2019s moral charge (as either villain or heroes, but never just as middlemen) is a direct effect of their particular \u2018in-between\u2019 position.<\/p>\n Mintz\u2019s (1956) account of the higgler, or marketplace peddler, provided a useful starting point. He shows how middlemen ground their craft in fine-grained, context-specific knowledge \u2014 from the perishability of avocados to transporting eggs in the rainy season. This closely situated market knowledge lets them catch the moment that delivers profit, mastering what any single farmer lacks time to learn. It is through this knowledge that middlemen create value for themselves and others.<\/p>\n In \u2018The Stranger\u2019, Simmel (1908) shows that middlemen are structural outsiders, belonging to no particular family or land. This position produces moral ambiguity: their disinterestedness makes them simultaneously suspect and unusually trustworthy. What matters for our purposes is that both possibilities are always latent in the figure of the middleman \u2014 transcending any simple claims about their morality.<\/p>\n Geertz\u2019s ([1979] 2022) account of the suq puts flesh on Simmel\u2019s stranger and situates Mintz\u2019s higgler within a market dynamic marked by opacity. He shows how markets need middlemen to function: as prices and availability constantly shift, traders need someone who works not through family ties but through mobility \u2014 able to move between and connect market actors, unconstrained.<\/p>\n For us, three key points emerge from the above: middlemen provide situated knowledge (Mintz), they occupy a structurally produced and morally ambiguous role (Simmel), and they produce value, including their own, by navigating what others encounter as opacity (Geertz). We use these three points to show how the middlemen we\u2019ve encountered in our research into fakes and global health are three-dimensional characters, which are structurally specific but open-ended regarding what they know and what service they deliver. Each of the contributions to this series illustrate different ways in which middlemen are formed by and in turn form global health\u2019s institutions, discourses, and practices.\u00a0<\/p>\n Bandora\u2019s account of suitcase traders<\/strong> in Dar es Salaam\u2019s cosmetics marketplaces shows how traders cultivate situated knowledge of these vibrant commercial spaces. Though cosmetics may seem distant from public health, regulators frequently invoke counterfeit cosmetics as a proxy for fake medicines, and in popular imagination cosmetics occupy a space adjacent to medical products. Suitcase traders leverage a layered understanding of markets, customers\u2019 desires, and their anxieties offering goods with the allure of distant origins while assuaging fears about counterfeits.<\/p>\n Zinati explores three middlemen in Iran\u2019s pharmaceutical trade in times of international boycott: street peddlers (dalals), pharmacists, and diaspora travellers. <\/strong>Dalals vouch for black-market drugs by combining access to illicit suppliers with pharmaceutical expertise. Pharmacists sell not only official Iranian drugs but also under-the-counter brands kept out of reach by sanctions and law. Diaspora travellers, meanwhile, express love for those left behind by bringing back commodities of health and wellbeing.<\/p>\n Peete\u2019s account of Tanzanian retail pharmacies<\/strong> reveals a gap between the formal register of state regulation, which pharmacy workers are trained to uphold, and their customers\u2019 colloquial health desires. Navigating the awkwardly overlapping roles of business owner, pharmaceutical specialist, and customer advisor, pharmacy workers find themselves interpolated into middlemen.<\/p>\n Thakur traces how pharmaceutical wholesalers<\/strong> in north India navigate claims to trustworthiness in a context where fakeness and fraud are assumed to be ever-present. She shows how online and in-person sellers each demonstrate care and attention to customers while casting doubt on the other\u2019s sincerity and safety. Each of them competes for the status of trusted middleman.<\/p>\n Goodman\u2019s analysis of a participatory theatre<\/strong> production about vaccine rumours in Mombasa depicts audiences as middlemen who traffic and connect scales of fakes. In a context where opacity is the norm and public health claims are met with suspicion, audiences share information, cobble together rumours, and debate their validity. They position themselves as arbiters, even if the certainties they produce are ephemeral.<\/p>\n Hanrieder and Januschek examine labour recruiters<\/strong> who face accusations of \u2018brain drain\u2019 for recruiting nurses from low-income countries to higher-paying Germany. Though officially sanctioned by the German state, they are simultaneously held at arm\u2019s length and seen as necessary yet suspect. Navigating this ambiguity requires actively performing their ethical credentials to multiple publics, shoring up the reputation on which their business depends.<\/p>\n Hornberger traces the rise and fall of the global health IMPACT taskforce<\/strong> to fight fakes through the lens of the middleman, showing how its moral valence could flip abruptly from indispensable broker to parasitic actor. IMPACT brought together WHO\u2019s standard-setting authority, Interpol\u2019s law-enforcement power, and big pharma\u2019s technical expertise, and was initially celebrated for convening this unlikely trio around a shared problem. Yet this capacity for intermediation became its undoing: once WHO\u2019s links to industry were judged inappropriate, the taskforce\u2019s value as a connector was reframed as undue influence, threatening both WHO\u2019s integrity and equitable access to safe medicines.<\/p>\n ***<\/p>\n These contributions draw inspiration from earlier anthropological work on middlemen that not only dissolved the hero\/villain binary but also helped us focus on the material, practical, and performative value that middlemen bring to global health. They also showed us how middlemen\u2019s reputational instability is borne of the same source from which they derive their value.<\/p>\n We also realised that we were charting new ways of thinking with middlemen for critical global health as a whole. This matters because global health has grown at a staggering pace and become an object of critical scholarly inquiry, with scholarship exposing a central contradiction: its stated aims of closing health inequities are at odds with its observable outcomes (e.g. Adams 2016; Adams et al. 2024; Biruk 2018; Dilger et al. 2025; Erickson 2015; Graham 2019; McGoey 2015; Hunter and Murray 2019; Kingori and Gerrets 2019; Nguyen 2010; Parker and Kingori 2016). How has global health survived rather than crumbled under the weight of this contradiction? The answer is middlemen, who thrive in environments of structural and moral contradiction, bridging gaps without rocking the boat. Our point is that middlemen deserve scrutiny alongside critical global health\u2019s more familiar personae of patients, clinicians, and philanthropists. What they help us see is that global health is less a superhighway than an unmapped, lucrative, bumpy road that is best navigated through know-how acquired on the fly.<\/p>\n Middlemen boast of making do with flair, acting in the moment, connecting people, things, and markets. Yet a counterintuitive corollary of this agility is their cultivated invisibility: their effectiveness often depends on fading into the background, covering their tracks, evading audit, or letting others claim the credit. This strategic self-effacement is no small reason why middlemen are so frequently misrecognised as redundant or corrupt or simply absent from dominant accounts of global health. Bringing them into view \u2014 attending to their situated knowledge, improvisational skills, and the networks they hold together \u2014 is, we argue, central to the practice of critical global health scholarship.<\/p>\n Provocations<\/strong><\/p>\n We offer here a primer for thinking with middlemen within critical global health, organised into a set of provocations that evoke\u2014rather than codify\u2014the shifting, situated ways in which middlemen work and what middlemen are.<\/p>\n 1.\u00a0\u00a0\u00a0\u00a0 Middlemen build connections and move across scales and registers<\/p>\n Middlemen do more than connect two points, buyers and sellers, for example; they collect and leverage information across global health\u2019s vast geographical distances, supply chains, and affective registers. Bandora\u2019s suitcase traders operate in a field of uneven regulation, attracting customers by meeting desires for cosmopolitan wellness products while promising safety. Similarly, Goodman\u2019s street theatre audiences mediate concerns about vaccine safety. Both arbitrate fakeness, discerning vexatious rumour from useful information, and both mediate fears of the fake \u2014 fears rooted in suspicion of the open borders through which cosmopolitan products necessarily flow.<\/p>\n 2. \u00a0\u00a0\u00a0\u00a0Middlemen are found at the disjunctures in systems<\/p>\n To dismiss middlemen as morally corrupt underestimates their essential role in a wider system. Because of their interstitial and seemingly underdetermined role, middlemen are often and easily portrayed as bad apples who clog up the system. Yet interstices are exactly the site of their work: they insert themselves and do the work that allows an otherwise disjuncted system to deliver. For example, in the context of pharmaceutical scarcity in Iran, Zinati\u2019s street dalals<\/em> and official pharmacists deliver consumer choice and relative abundance.<\/p>\n 3.\u00a0\u00a0\u00a0Middlemen rarely come alone<\/p>\n Middlemen are often depicted (see above) as isolated occurrences. We disagree. Middlemen work in clusters and form chains of transactions with one another. Middlemen work at various points in supply and distribution chains and at various regulatory intersections. On policy level we have Hornberger\u2019s taskforce pave the way for new security interventions into the pharmaceutical supply chain, while further down the line we have Thakur\u2019s wholesalers mediating their customers\u2019 need for care. Sometimes, as middlemen cluster along the supply chain, they do not just cooperate but also compete with each other, and in so doing mobilise the very suspicions that are often levelled against them.\u00a0<\/p>\n 4. \u00a0\u00a0\u00a0Middlemen are nobody and everybody<\/p>\n Middlemen, their practices, and what they know cannot be generalised or characterised through a particular profession or body of expert knowledge. They are not a stable, identifiable category as such; they are always particular and contingent in where they insert themselves and what they do. As global health workers, they develop their skill by handling global health commodities or particular constituencies on either end of the supply chain. They also become global health workers by virtue of having connections that happen to be part of global health networks. Any kind of skill and expertise can be mobilised into a service that can be recognised for its value: here the ambassador\u2019s wife in Hanrieder and Januschek\u2019s contribution stands out. She used her networks to become a nurse broker.<\/p>\n 5. \u00a0\u00a0\u00a0\u00a0\u00a0Being nobody and everybody, however, means that middlemen constantly have to announce themselves<\/p>\n Because the role of the middleman in global health is radically contingent and ephemeral, middlemen must constantly make themselves seen and heard. In practice, this is about first inventing new idioms of plausible professionalism in the absence of recognisable qualifications. Props and charisma play an important role in their work of performative persuasion: the suitcase of Bandora\u2019s trader, for example, convinces his customers that he is bringing goods with a cosmopolitan appeal. Or it involves the mastery of expert terms, as seen in the pavement traders for Iranian medicines in Zinati\u2019s account. Often it is a combination of all these alongside the invention of self-regulating quasi-professional associations, such as those described in Hanrieder and Janauschek\u2019s account.<\/p>\n 6. \u00a0\u00a0\u00a0\u00a0Global health\u2019s virtues attract middlemen<\/p>\n Middlemen are often the \u2018pop-up\u2019 or ad hoc merchants of global health, central to operations but strategically invisible to organisational structures or formal budget lines. As such, their skills remain formally illegible within global health institutions, so much so that their work is regularly read as corrupting or criminal. Yet, for middlemen, this is a reputational risk worth taking. The field of global health offers much-maligned middlemen a chance to burnish their image as global health workers. As Hornberger shows, an international taskforce brokered a reputationally risky collaboration among Interpol, the pharmaceutical industry, and the WHO. This allowed potentially suspect members of the taskforce like police and big pharma to adorn themselves with the shiny moral claims of protecting health.\u00a0<\/p>\n 7.\u00a0\u00a0\u00a0\u00a0 Middlemen do not rock the boat and yet can be read as a critique<\/p>\n Because of their relative invisibility, middlemen don\u2019t rock the boat. They bridge gaps without altering the underlying situation. Found where things don\u2019t add up, they make the incommensurable manageable. Zinati shows how middlemen help Iran maintain its official guise of pharmaceutical self-sufficiency while ensuring that customers can still access international drugs. In Peete\u2019s account, pharmaceutical technicians shift between a nationalistic regulatory register and consumers\u2019 felt entitlement to free choice. In Hanrieder and Januschek\u2019s telling, middlemen secure Germany\u2019s access to health workers from the global South, albeit \u2018ethically\u2019. Attending to middlemen makes visible the contradictions between global health\u2019s avowed mission and its observable shortcomings. In absorbing global health\u2019s less palatable aspects, middlemen offer a peculiar form of critique and an anti-politics: this is the middleman\u2019s intervention in critical global health studies.<\/p>\n Conclusion<\/strong><\/p>\n In our work, we encountered middlemen as lively figures who broadcast a buoyant pride in their craft. At the same time, they were very aware of their often morally embattled reputation. Rather than dismissing or rationalising middlemen and their work, we take account of both their moral and structural positionalities.<\/p>\n Structure matters for middlemen but does not wholly define them. As we lay out in our provocations, the power of middlemen lies in their capacity to make something out of nothing. They excel at producing credibility, value, and usefulness through their sheer effervescent exuberance, navigating across scale and register. And they are masters of deploying both visibility and invisibility in both obvious and the most unlikely of spaces and places.\u00a0\u00a0\u00a0\u00a0<\/p>\n In overlooking middlemen, we miss much about how global health functions. Global health is both a practical and moral project, yet its various parts rarely add up to a coherent system. Many have blamed this on profit- and market-driven rationales, calling for a reinvention of global health\u2019s mission. Middlemen awkwardly interrupt this diagnosis by showing that health is always already a commodity. When we look at middlemen, we see who does the dirty work that sustains the fiction that health and commodities could ever be separate.<\/p>\n We stumbled onto middlemen through our empirical work on fake drugs. This is not a coincidence. Yet, we did not find middlemen to be the smoking gun behind a global conspiracy to sell fakes. What connects the two is, for lack of a better term, their respective dodginess: both are thick with associations of the illicit, shadowy, and corrupting \u2014 that which should not be there. As a result, we speculate, some critical global health scholars may encounter these figures but turn away, finding them distasteful or inconvenient, and relegate them to the margins.<\/p>\n \u2018Staying with\u2019 this dodginess allows middlemen to emerge from the margins, with their own, albeit peculiar, main character energy. Thinking with and about middlemen allows us to take a much fuller account of the charged moral terrain of global health, rather than simply evaluate the workings of global health as moral or immoral. To stay with the dodginess is to refuse to look away from that which discomforts us and to keep our gaze on the intricacies of the apparatus.<\/p>\n [1]<\/a> Just to be clear: middlemen<\/em> are, more often than not, also women, even if the label might suggest otherwise. Going forward, however, we will continue to use the term middlemen<\/em>. We do this partly for readability, as neologisms such as middle-women<\/em> or middle-people<\/em> interrupt the flow and introduce unnecessary linguistic stumbling blocks. But more importantly, we do so because middlemen<\/em>\u2014much like the broker<\/em> or the stranger<\/em>\u2014are first and foremost relational categories, not descriptions of an essential or fixed identity. 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