What counts in global health
— Reviewed by
Vincanne Adams, ed., Metrics: What Counts in Global Health. Durham, NC: Duke University Press, 2016. Paperback, 258 pp. with ill, $24.95. ISBN: 9780822374480.
The current global health landscape of action is situated beyond the nation-state but within multinational markets. Metrics: What Counts as Global Health (2016) expertly unpacks how and with what consequences these structural arrangements are made possible through the development and sophistication of metrical forms by which global health data is collected, shared, and negotiated between different parties. Vincanne Adams has brilliantly edited a volume that articulates a coherent, complex, and compelling narrative about how the epistemological frame of global health metrics serves political and economic interests, beyond those related to health promotion alone.
The volume discusses how metrics advance an ideal of efficacy afforded by specific types of evidence that function as the gold standard for demonstrating the value, both humanitarian and actuarial, of global health interventions. However, the authors of this volume make clear that the discussion about what counts as efficacy and evidence is not just a scholarly debate but an essential site for understanding how the political economy of global health today is continuously shaping the lived contexts in which health interventions are experienced by subjects living and working in areas with scarce or no access to biomedical healthcare.
The volume is composed of eight chapters, providing a rich variety of explorations of global health metrics from the ground, including qualitative research carried out in Malawi, Nigeria, Senegal, Haiti, and the United States, mapping how the world-making potential of global health interventions is tied to the production and circulation of standardised forms of counting. Part I of the volume draws on two ethnographic cases to explore the production of maternal health statistics in Malawi and Nigeria, and asserts that while metrics may appear as neutral facts, they bring with them a political legacy that ties economic rationalisation to the management of life and death through the exercise of counting. As such, data production (in global health) is a political act. Akinyemi Oni-Orisan (chapter 2), exploring the case of maternal health in Nigeria, describes the productivity of metrics associated with its supposed neutrality as a form of political efficacy, insofar as getting good numbers was a requirement for successful governance, and, therefore, more aid. She defines political efficacy as the background of metrics production, which poses consequences for both ‘how patients are treated and who wins elections’ (p. 99).
In Part II, the political analysis of metrics is deepened by exploring how global health metrics affect states’ and local communities’ possibilities for achieving sovereignty, or at least recognition of their autonomy to make decisions about health interventions. Marlee Tichenor (chapter 4) observes how health care professionals negotiate whether the data collected on the ground about malaria control in Senegal is circulated and used for political interests. Molly Hales, doing ethnographic fieldwork with members of a Native community in Alaska (chapter 5), shows that mainstream forms of measuring efficacy of health interventions must be negotiated. She writes, ‘[T]he purportedly apolitical language of quantitative evidence masks the post/colonial power dynamics at play here’ (p. 140), as the success of culturally sanctioned behavioural health programmes are paradoxically tied to federal government funding rules, which in turn strip the community of their cultural knowledge about the causes and treatments of emotional distress.
In the third part, the volume changes gear, surveying the current financial landscape in which metrics enable the commensurability of humanitarian and profit-making enterprises. As Susan Erikson discusses in chapter 6, with market and humanitarian logics made commensurable through the abstraction afforded by statistics, an important transition occurs in the political economy of global health, from accountability metrics to value metrics, which are used to anticipate the actuarial worth of interventions while funded interventions may or may not foster some form of health outcomes. Erikson explains: ‘Statistical metrics and market logics can bypass local realities altogether and still meet investor expectations’ (p. 160). Due to the emphasis on measuring the potential scalability of interventions across contexts despite their efficacy, such economic opportunity for the marketization and commodification of health poses moral risks to the very practice of global health as a utopia based on the human right to health. This situation is further complicated, as Lily Walkover shows (chapter 7), when NGOs developing health promotion interventions struggle to remain accountable to the communities they serve while they follow donors’ demands for short-term quantifiable outputs.
In the fourth part, the issue of negotiating what counts as evidence continues, providing a timely critique of the limitations and effects of using randomised control trials as a gold-standard research method. In a provocative discussion, Carolyn Smith-Morris (chapter 8) discusses the challenge she faced in making qualitative results relevant to the research team when employed in the qualitative arm of a clinical trial to support veterans with spinal cord injuries in the United States. Discussing the hierarchies of evidence in clinical trials, she argues: ‘While the benefits of RCT methodology and evidence gathering are not disputed, the gap between outcomes and the contextual evidence that explains those outcomes is wide and growing’ (p. 199).
Furthermore, we learn that long-term change in impoverished communities is usually not significant for international donors. Pierre Minn (chapter 9) discusses how health care capacity-building through a health partnership between Konbit Sante and the Haitian national health system is inadequately measured by discrete forms of counting. After observing and doing interviews with health professionals and volunteers from the US NGO, he argues that excessive preoccupation with numbers as a way to make sense of the success of interventions erases achievements that are framed in terms of processes rather than outputs, disempowering local professionals from actively using the data they collect for others, and facilitating the implementation of vertical interventions that do not necessarily consider local expertise and priorities.
After reading this book, I am left with the impression that global health continues to face an important danger, namely, that the promotion and requirement to exclusively use metrics when accounting for efficacy of interventions might end up perpetuating the reproduction of global inequalities. Nevertheless, such a critique could also work as a call for all interested in the social science of global health. In a brief but powerful epilogue, Adams points to the potential of ethnography and other ‘slow research’ methods to unsettle the truth of numerical forms of evidence and to offer alternatives for the realisation of the life-enhancing potential of global health interventions. For when evidence required to justify funding for interventions does not acknowledge the lived expertise that people have about their own lives and medical conditions, or when it bypasses the real health care needs of the communities supposedly served for the profit of global markets, the incorporation of ethnography as a way to measure the process and the impact of global health interventions becomes even more significant. Maybe then, if we strive to illuminate the real mechanisms that make some interventions work, those that are valued by global health practitioners and recipients of medical care alike, we can contribute to making some health interventions life-giving for the long term.
Considering the currency of public debates in health care policy that are framed in terms of cost-effectiveness and the ubiquity of surveys measuring quality of care, this volume speaks to ongoing discussions in the global North as much as it does to the global South. As a well-informed, thought-provoking, and seamlessly edited piece, this book is highly recommended not only for critically engaged postgraduate students and researchers in the social sciences who are interested in global health but also for other health professionals and epidemiologists keen to explore how the use of metrics as an exclusive form of evidence simultaneously reveals and conceals efforts in both the quality and delivery of health care.
About the author
Ignacia Arteaga Pérez is a final-year PhD candidate in medical anthropology at the University College London, UK. Her doctoral dissertation examines the world-making potential of caregiving projects for people affected by colorectal cancer in the UK.