The work of evidence in critical global health

The think pieces assembled in this special section of MAT offer a critical examination of the paradigms and values that undergird the ever-expanding field of global health and an ethnographically informed contribution to a people-centered and politically relevant social theory for the twenty-first century. Drawing on research in the United States and abroad, from policy to medicine to street life, and from stories to metrics, our individual and collective work bridges the fields of medical anthropology and science and technology studies with emerging debates on evidence making, efficacy, and ethics. We place ethnography and theory at the center of an alternative critical perspective both in and of global health.[note 1]

So, what do we mean by ‘critical global health’?

Geographically distant places are sutured together by the larger structures of science, finance, and policy that claim the mantle of global health, and come to resemble each other when viewed through the lens of evidence. Yet, as articulated in these Think Pieces, ‘critical global health’ displaces our attention from the standard geographic markers and objectivity strategies of global health, and returns us to questions about people, the politics of truth and accountability, and critical social theory. It begins from the idea that ethnographic methods can highlight the conceptual and practical conundrums arising from contested notions of evidence and efficacy. The ‘global’ of global health must thus be interrogated as both a political accomplishment and a means of producing other kinds of evidence.

Evidence making is, after all, not only the domain of global experts, but an ethical and political proposition that knowledge can come in many forms and be distinctively mobilized. It is a process available to myriad actors as they navigate contemporary medical, humanitarian, and governmental regimes in search of rights and resources. Experiences, often unpredictable, of the social, political, and medical effects of interventions also give rise to new claims of efficacy, new regimes of truth and falsity, and new political and epistemological engagements with outcomes that matter to people. These cumulative experiences form alternative, practice-based forms of evidence that can challenge orthodoxies and perceptual deficits of all kinds and are, in our view, the very fabric of alternative theorizing in global health and beyond.

The richly textured ethnographic think pieces presented in this special section also tackle problems of evidence and efficacy as complex forms of ethical and theoretical engagement in contexts of neoliberalism, war, technological innovation, inequality, and structural violence. Without stealing their thunder, we orient readers toward the following points of interrogation in the essays:

How can the effort to ‘people’ global health continue to challenge our notions of what kind of theorizing we can do today, and what forms of on-the-ground engagement are desirable and possible? What kinds of evidence count in an epidemic outbreak in Venezuela, and when might too much evidentiary information undermine the possibility for communicative health rights? How, in the United States, do insurance industries work together with both research and clinical practice to generate evidence that pushes us to the limits of ethically comfortable efficacy in later life? What kinds of evidence must be corralled to manage pregnant, homeless, and addicted women in the United States as problems of rational choice rather than of urban poverty? How is metabolic disease in India as much a product of perceived evidence of dietary preferences as it is of environmental and structural inequalities, and how are these forms of evidence managed in clinical settings as evidence of death in life? What institutional forms of evidence must be produced to make disabled US veterans into war heroes, and what are the ethical risks involved in doing so? How do randomized controlled trials undermine our ability to do efficacious global health work, while linking our ethical commitments to neoliberal financial reforms that promise their own forms of efficacy?

These questions are critically addressed and at least provisionally worked out in the essays that follow. These pieces are exemplars of critical global health in action, persuading us not only that evidence is not a given in the world of health today but neither are efficacy or mainstream understandings of the biosocial and the political. They remind us that knowing how evidence and efficacy work together is a matter of local and specific engagements, even when these engagements are entangled with global practices. This set of concerns is raised in the final essay that serves as a coda, asking again not only ‘What is critical global health responding to?’ but also ‘Where do these insightful essays suggest we go from here?’  

About the authors

Vincanne Adams, PhD, is Professor and Vice Chair in the Department of Anthropology, History and Social Medicine at the University of California, San Francisco. She is coeditor of the Duke University Press book series entitled Critical Global Health: Evidence, Efficacy, Ethnography. She is also the editor of Metrics: What Counts in Global Health (Duke University Press, 2016) and author of Markets of Sorrow, Labors of Faith (Duke University Press, 2013) as well as other ethnographies. She is currently working on several other projects, including one on pesticides and pediatric health in the United States and another on Tibet and science.

João Biehl is Susan Dod Brown Professor of Anthropology and Woodrow Wilson School Faculty Associate at Princeton University. He is also the codirector of Princeton’s Global Health Program. Biehl is the author of the books Vita: Life in a Zone of Social Abandonment (University of California Press, 2005) and Will to Live: AIDS Therapies and the Politics of Survival (Princeton University Press, 2007). He coedited the books When People Come First: Critical Studies in Global Health (with Adriana Petryna, Princeton University Press, 2013) and Subjectivity: Ethnographic Investigations (with Byron Good and Arthur Kleinman, University of California Press, 2007). Biehl is also the coeditor (with Vincanne Adams) of the Critical Global Health book series at Duke University Press.

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