Review Essay: The Politics of Global Health

In 1968, Monsignor Ivan Illich delivered a memorable speech, titled “To Hell With Good Intentions,” challenging American volunteers to Latin America to recognize “[their] inability, [their] powerlessness and [their] incapacity to do the ‘good’ which [they] intended” (1968). Three recent books–Ralph R. Frerichs’ (2016) Deadly River: Cholera and Cover-Up in Post-Earthquake Haiti, Judith Lasker’s (2016) Hoping to Help: The Promises and Pitfalls of Global Health Volunteering, and Vincanne Adams’ (2016) edited volume Metrics: What Counts in Global Health—written from the disciplinary perspectives of Epidemiology, Sociology, and Anthropology, respectively, take up Illich’s provocation, capturing the oscillating violence and care inherent in global health’s well-intentioned enactments in a vastly unequal world. The texts intersect scholarship in critical global health studies, challenging received knowledge about projects ranging from epidemic responses to global health volunteering to clinical trials and behavioral health interventions. The authors urge us to look beneath the surface of global health’s success stories, propped up by quantitative evidence and sentimental representations of suffering strangers waiting to be saved by Northern science, technology, and do-gooders.

Global health is an unwieldy thing, difficult to pin down, yet something everyone agrees is worth doing (Fassin 2012, Taylor 2018). Colonial legacies and forms of expertise about the “tropical” world have become naturalized as global health science, with implications for what and whom global health is not (Meyers and Hunt 2014, Geissler et al 2016, Packard 2016), and global health has become institutionalized in Northern universities and curricula where students and faculty relish the opportunity to gain hands-on experience working in hospitals, NGOs, and research institutions in the Global South (Kenworthy, Thomas, and Crane 2018). The proliferation of clinics, research projects, and technologies across the globe has reconfigured local identities, social relations, economies, and forms of care, prompting anthropologists to take interest in global health as an object of study and critique (Biehl and Petryna 2013, Fan and Uretsky 2017). Indeed, global health has been a fecund site of value production for anthropologists, who teach courses and publish articles and books that position them as insistent critics of global health’s logics, assumptions, and universalizing agendas (see, for example, the collection of books in Vincanne Adams and Joao Biehl’s series at Duke University Press, “Critical Global Health”). In what follows, I situate these three texts in existing literature that engages critically with global health. This review essay inevitably betrays my disciplinary lens, yet I cannot emphasize enough how fruitful it was to read three texts written from different perspectives and for different audiences alongside one another. Doing so reveals how epidemiological, sociological, and anthropological tools hold different but complementary potential for deepening our understanding of global health’s intentions, actors, unintended consequences, and transactions.

On epidemics, crises and reparations in Haiti

Retired professor of epidemiology and public health Ralph R. Frerichs’ compelling Deadly River (2016) tells the story of Haiti’s 2010 cholera epidemic, the worst in recent history. The book is a detective story that documents how epidemiologists and others sought to quantify, decode, and combat cholera, and provides a firsthand look at the politics of medical humanitarianism. Frerichs draws primarily on firsthand accounts from the protagonist of his story, French epidemiologist Renaud Piarroux who was in Haiti during the epidemic, which are complemented by analyses of media coverage and selected maps, charts, and graphs. As Frerichs demonstrates, the hunt for the origins of the epidemic was politicized and fraught because powerful entities—the UN and WHO—had vested interests in obscuring the fact that UN Nepalese peacekeepers, part of MINUSTAH’s (United Nations Stabilisation Mission in Haiti) effort to preserve “law and order” and known to Haitians as “occupiers,” unwittingly carried the bacteria to Haiti. Frerichs recounts the timeline of events and knowledge production during the epidemic to frame a battle between two theories of cholera’s origin (an environmental theory vs. a human-centered theory). Frerichs’ account is at its strongest when he draws on his expertise as an epidemiologist to undertake critical readings of artifacts of knowledge that played a key role in how scientists and the public interpreted the epidemic’s events. In one such case, he critically examines a map disseminated by the UN’s Office for Coordination of Humanitarian Affairs (OCHA), showing how small shifts in language in the map’s legend—which conveniently left communes near MINUSTAH’S camp out of the shaded “zone where cholera began”—shifted attention away from the human transmission hypothesis in an act of “cartographic deception” (ibid.: 73).

In resonance with points made by the contributors to Metrics, Frerichs illustrates how numbers and counting carry with them the assumptions and politics of those who use and bring them into being. For example, only MINUSTAH troops who exhibited “severe diarrhea and dehydration” came to count as “cholera” cases and, in the early days of the epidemic, cholera deaths that occurred in Haitian homes were not included in official statistics (ibid.: 45). These genres of concealment resonate with scholarship on non-knowledge, situated ignorance, secrecy, or unknowing as constitutive of knowledge, itself always a partial and situated formation (Pred 2006, Geissler 2013, Decoteau and Underman 2015, Viatori 2016). As an anthropologist of science, I was struck throughout the book at how the aesthetics of “evidence” (maps, references to “data”) count as much or more than the content or quality of data themselves (Hodžić 2013).

Yet, even as Frerichs convincingly shows how the clear interests of the UN and its affiliated scientists enabled the science that most benefited its position to rise to the top despite being “wrong,” he does, by virtue of his academic training, believe in a “pure” science that can uncover the truth. For example, he casts the epidemiologist-hero at the center of the story as a model scientist who “fearlessly follow[s] where the data lead,” juxtaposing him with other scientists whose conclusions and explanations were marred by politics (2016: 210). As much work in Science Studies and Anthropology has shown, science is never objective, pure, or neutral; data are never fully alienated from their processes of production and are often prefigured by baked-in ways of seeing (Latour and Woolgar 1979, Epstein 1998, Daston and Galison 2007, Gitelman 2013, Halpern 2015, Biruk 2018). Yet, firsthand exposure to epidemiological “ways of seeing” reminded me that it is the slower research of Anthropology and the ability of its practitioners to spend long periods of time in the field that enables them a different perspective than is afforded epidemiologists, who operate to save lives in rapid time and rely on fast evidence (Adams, Burke, and Whitmarsh 2014).

Deadly River exposes how hierarchies of life structure the speed and efficacy of response to human emergencies; however, a more sustained framing of the ways Haiti has come to be seen as exceptional, as the most pitiable and unlucky state in the world, would have enhanced Frerichs’ analysis (Trouillot 1990, Benedicty-Kokken et al 2016). Meaningful discussion of Haiti’s history as the first free slave republic, and of the profound role that race and racialization play in the ways non-Haitians continue to imagine and narrate Haiti and its crises would bolster Frerichs’ points about the “cheapness” of Haitian lives. Numerous scholars have by now analyzed Haiti through the lens of critical humanitarianism, highlighting, for example, its NGOization. Attending to legacies of debt, financial colonialism, and neoliberal adjustment (see Mullings et al 2010) and the mutation of “settler-humanitarianism” that operates in Haiti (Maxwell 2017) complicates the image of Haiti as simply unlucky or, in Frerichs’ words, a “parched landscape awaiting a match” ahead of the 2010 epidemic and earthquake (2016: 226), particularly considering U.S.-based disaster capitalism’s uncanny ability to turn humanitarian work into highly profitable business amid the rise of new racial capitalisms furthered by carceral projects (Adams 2013, Forgie 2014, Wang 2018).

As Susan Erikson (2016) notes in her contribution to Metrics, new financial arrangements in global health are driven by the assumption that one can make money doing “good things,” evident in responses to natural disasters like those faced by Haiti (see also Mei 2017 on global health’s trenchant “market optimism”). In her critical account of flows of international aid, Monica Krause (2014) shows that the main focus of NGOs and humanitarian organizations is to produce more “projects,” converting (potential) beneficiaries themselves into commodities in market economies. Indeed, as Judith Lasker (2016) points out in Hoping to Help, Haiti is by far the top destination for U.S. volunteers, most of whom have very few relevant skills, yet find sentimental value in doing good in a needy and desperate locale, a dynamic that came to the fore in the wake of the 2010 earthquake (Schuller 2016). In her fieldnotes, Lasker observes that volunteers ride in the flatbed of a truck enclosed in fencing (“affectionately referred to as ‘the cage’”) as they pass through Port-au-Prince’s streets (2016: 45). Haiti, in this snapshot, becomes synonymous with criminality, where whiteness must be protected from blackness, clean from dirty, safety from danger (though Lasker does not analyze such optics). Haiti has long been, in the Northern imagination, “matter out of place” (Douglas 1966) and attention to enduring histories and geographies of containment would helpfully contextualize the events and rhetoric of 2010, largely presented as a sudden and unfortunate tragedy, rather than as engineered by global forces and politics over long historical time (Button and Schuller 2016, Barrios 2017).

The logics and technologies of containment and quarantine—and even the global community’s tepid interest in finding the source of epidemic cholera in Haiti–must be read against the backdrop of immediate responses to the successful slave uprising in Saint-Domingue against the French; U.S. slave owners at the time were fearful that black revolution might spread to the U.S. Globally dominant states collaborated with aggrieved France to isolate Haiti from trade circuits and to refuse it international recognition. The fear of (free, unfettered, risky) blackness continues to manifest in present day U.S. neo-imperial relations with Haiti, relations that operate symbolically and materially through racialized contagion, as in the assumption of black criminality that justifies U.S. and foreign occupation to maintain “law and order” or through efforts to generate compassion via visual representations of pitiful suffering of racialized others often, tellingly, termed “humanization” (Butt 2002, Fassin 2011, Robbins 2013, Beckett 2017). A historical lens brings to light a telling juxtaposition between the failure of the 2011 petition filed against MINUSTAH on behalf of Haitians who died or were injured from cholera for “monetary compensation for their losses” (Frerichs 2016:197) and the success of France’s demands that Haiti pay reparations for French “property” lost (enslaved people), a debt that took well over a century to pay off. Humanitarianism and “doing good”—logics that underlie the projects described in these three volumes—are racialized, evident in the trope of heroic Whiteness and abject or risky blackness that gives “good intentions” their meaning (Benton 2016a). Piarroux, described by Frerichs as a, “modern day John Snow who would unravel the causative complexities of cholera in Haiti” (2016: x), is a figure who joins a long historical parade of white men as heroic saviors of suffering others (see Vaughan 1991 on “jungle doctors” and Redfield 2012 on “cowboy doctors”).[1]

Frerichs is upfront about his intention to tell the story of cholera from the point of view of Piarroux, his “main character” (2016: xi) (a device that serves the book well), yet it is worth noting that the book fits squarely in a particular genre of science writing that reinforces the existence of an “underdeveloped subjectivity endowed with features such as powerlessness, passivity, poverty, and ignorance, usually dark and lacking in historical agency, as if waiting for the (white) Western hand to help subjects along…” (Escobar 2011:275). Scholars have captured the experiences, expertise, and skill sets of local intermediaries, experts, research assistants, and minor actors long overlooked in scholarly and popular literature on science, medicine, and technology, which tends to focus on the lone (often white, male) scientist rather than the networks, appropriation, and exploitative relations through which Western “knowledge” is produced (e.g., Kingori 2013, Graboyes 2015, Jacobs 2016, Mavhunga 2018). While other characters do seep into Frerichs’ narrative here and there, the focus on Piarroux inevitably overshadows the immense labor undoubtedly done and expertise proffered by those other actors who contributed to his investigations.

Finally, the outbreak of a parallel “epidemic of signification” (Treichler 1987) alongside the 2010 cholera epidemic invokes and reproduces Haitian culture as risky (the figure of vodou for example, see Ramsey 2011); “culture” becomes an alibi for the failures of states or other powerful people and institutions to address or stem the deaths of poor black and brown people. In Frerichs’ account, as well, culture becomes too easy an explanation—in diverting attention toward (and Othering) victims rather than perpetrators and structural violence—for what he terms “irrational” or “illogical” explanations about cholera, such as accusations of cholera-related witchcraft (2016: 137) (cf. Mkhwanazi 2016). Anthropological attention to dynamics and historical relations between the parties invoked in rumors, idioms, and stories about the origins or events of epidemics (occupier/occupied, victim/savior, white/black, rich/poor) reveals, however, the embedded claims to justice and redress they often carry with them and reframes rumor as legitimate critique or commentary on social issues (Farmer 1992, Kroeger 2003, Briggs and Mantini-Briggs 2004, James 2012, Paik 2013, Biruk 2014, Wilkinson and Fairhead 2017).

Frerichs’ book makes an important contribution to our understanding of what happened behind the scenes in Haiti in 2010, a rare occasion in which science (in the heroic form of Piarroux) finds that conspiracy theories circulating among Haitians about MINUSTAH are actually accurate. The book is accessible and teachable, yet would be complemented by scholarship that frames humanitarian crises through historical, structural, and racialized lenses. In thinking through the congeries of events that constitute the 2010 cholera epidemic in Haiti, anthropologist Deb Thomas’ “reparations as a framework for thinking” (2011) is especially useful: Thomas theorizes reparations as a mode of knowledge production that seeks to reveal hidden histories, to focus on structural (rather than culturalist) explanations, to pay close attention to transnational and imperial relations and transactions, and to challenge dominant liberal human rights frameworks. Such a framework can ensure that we not overlook how structural violence—rather than mere context for analyzing health and illness—has material and biological effects on populations made vulnerable by, for example, capitalism, colonialism, racism, and neoliberalism (Quinlan et al 2016, Duke 2017).

On asymmetrical gifts: Global health volunteering

Hoping to Help (2016), by sociologist Judith N. Lasker, is a timely contribution to a growing literature that examines the unintended consequences of well-intentioned efforts to help, improve, or fix other people’s problems. One of the strengths of Lasker’s book is its eminent readability, teachability, and accessibility to those involved in or interested in medical volunteering abroad (her target audience is “organizers, funders, volunteers and hosts” involved in international volunteer programs). Hoping to Help effectively serves as a best practices manual with guidelines for “doing good better.” Lasker takes as her entry point what she, borrowing from Dr. Neal Nathanson, dean of Global Health Programs at the University of Pennsylvania, terms a “tsunami” of volunteers. This “tsunami” has come about in the wake of crumbling health systems and brain drain following structural adjustment programs in the Global South, amid mass media coverage of volunteering among “suffering strangers,” celebrity volunteering, and the positive moral and intrinsic value assigned to volunteering, which also carries economic value as a line on a CV. Despite the rise of global health volunteering as an industry, Lasker points out that there is scant empirical research on the value of this enterprise, a gap her book aims to fill by bringing qualitative data to bear on debates that often polarize: Is volunteering abroad “good” or “bad”? Does it benefit the giver or receiver? Does it reinforce inequalities? Her answer is: “It’s complicated.”

Lasker’s methods are broad and far-reaching; her findings come from interviews (with around 120 individuals, including host-country staff in four countries, 15 volunteers, 27 officials of U.S. sponsor organizations, and global health experts) and an Internet survey of U.S.-based volunteer organizations. Lasker and her students also observed medical missions and conducted surveys of volunteers and host-country trainees before and after their experiences, as well as focus groups with the latter. Overall, from an anthropological perspective, I found the analysis of quotes or excerpts drawn from interviews a bit thin. Often, she seems to take the statements of interviewees at face value, sacrificing the analyst’s position, which might more rigorously consider how speakers’ positionality and interests color their comments. For example, in a discussion of how religious faith does or does not inform the work of volunteer organizations with the global health director of a Christian medical volunteer system, she seems to accept the division he draws between “evangelistic and religious activities” and “pure… health care” (ibid.: 26). As historians have shown, the roots of medicine in missionizing in the Global South, mean that healing the body is difficult to disentangle from “winning the soul,” a goal that persists and mixes with neoliberal logics in present-day global health efforts (Vaughan 1991, Comaroff 1993, Jennings 2008, Hardiman 2008, Boyd 2015).

Lasker’s book is at its strongest when it highlights dynamics often made invisible by the discourse of “doing good.” For example, Lasker’s discussion of the burdens volunteers put on local staff—who effectively become tour guides to naïve and ill prepared volunteers, even arranging their housing, transport, and interpreters—is enlightening and may help would-be volunteers to problematize their visions of themselves as the helpers (ibid.: 150). This also complicates the valence of the phrase “Do no harm,” which by now is most typically associated with the flow of medical students from North to South, clinical tourists who often engage in tasks or medical procedures well beyond their qualifications (Wendland 2012, Sullivan 2018) even as the assumptions they bring into the clinic may fly in the face of their local counterparts’ “very different embodied and moral and scientific understanding of their work” under conditions of normal emergency (Feierman 2011: 193; Street 2014). Yet, “harm” is more capacious, as indicated by the anecdotes in this book focused on the burden, rather than the relief, that volunteers bring to local staff.

Given Hoping to Help’s focus on volunteering and volunteers, it is productively read alongside accounts of the labor of volunteering for people in the Global South, who are often enlisted as home-based care volunteers, peer educators, recruiters for research studies, and so on with minimal to no pay, often with hope they will one day become salaried employees. As many have shown, the moniker “volunteer,” when applied to people from the Global South, especially amid the commodification of the imagined “grassroots,” operates mostly to obscure the work folks do by framing it as moral sacrifice rather than legitimate waged labor (Mercer and Green 2013, Nading 2013, Brown and Green 2015, Maes 2016, Wig 2016, Park 2017, Biruk and Trapence 2018). Juno Salazar Parreñas (2018), drawing on ethnographic work at orangutan rehabilitation centers on Borneo, meanwhile shows how the same task can simultaneously be compensated activity for local low-wage workers and commodity for vacationing “voluntourists.” Others document how attending paid trainings and workshops meant to build local volunteer capacity (or even participating in research for compensation) has, in some contexts, become a form of livelihood (Tostensen, Soreide, and Skage 2012, Carruth 2018). Further, hierarchies of life and value play out, often in racialized ways, between local and non-local volunteers or staff within the same organization (Redfield 2012, Benton 2016b). Tracking the rise of global health’s “other” volunteers alongside the boom in Northern volunteers draws attention to the perverse (racialized) logics of capitalism and the forms of value it produces: What does it mean, for example, when philanthropists willingly give money to naïve young white people who want to “save” Africans but refuse to give money to experienced black Africans because of worries about corruption (Iweala 2017)? Scholars have shown how focusing on voluntary labor and its culturally inflected meanings across contexts sheds new light on issues such as citizenship, labor markets, development, identity, and forms of belonging (Muehlenbach 2012, Brown and Prince 2015). Hoping to Help contributes to literature that examines how the Global South has long been a canvas upon which citizens of the North paint themselves and become global citizens (Mathers 2010, Schein 2015), but we should not lose sight of the ways local people, too, are engaged in their own becomings, and moral and economic projects (Swidler and Watkins 2017).

Lasker’s book complicates the simple view that volunteering is a gift given freely and altruistically: instead, the firsthand accounts collected in the book resonate with anthropologist Marcel Mauss’ famous contention that a gift is always “interested” (1925). It is through transactions and relations across difference that selves are fashioned, relationships established, hierarchies made or reinforced, and networks expanded. For this reason, the gift of volunteering cannot be fully understood without attention to colonial legacies, material inequalities, and racialized assumptions built into the industry in which it has become a commodity. Hoping to Help encourages us to dispense with the received knowledge that volunteering can only ever be a good thing, and provides readers with an entry point to questions around the ethics, politics, and entailments of well-intentioned gifts that, as Mauss suggests, might also be poisonous.

Lasker devotes an entire appendix to “recommendations for having the best possible global health volunteer trip” directed at those who plan to go on international service trips. Many of these pivot on giving the local community or local partners power or say in what goes on. Yet, terms like “mutuality,” “collaboration,” and “equality” in partnerships have been commodified and hollowed out: this is not to suggest they are not worthy goal posts, but to prompt us to think critically about how we might begin to assess whether real collaboration happened. For example, a local collaborator asked by a foreign volunteer about his experience is unlikely to complain given the inequalities structuring their relationship (cf. Crane 2010, Gerrets 2015, Okwaro and Geissler 2015, Herrick and Brooks 2018, Simwinga et al 2018). I hope this book—including the best practices she recommends—finds its way on to college or medical school syllabi, alongside Ivan Illich’s timeless and biting speech.

On the social and political lives of global health metrics

Frerichs and Lasker share an underpinning faith in data to tell us what is really going on: For Frerichs, it was the ways the science became “political” that allowed the “wrong” science to rise to the top and obscured the real origin of the epidemic. For Lasker, monitoring and evaluation, informed by metrics and indicators of success, hold the key to making global health volunteering more effective; she suggests, for example, that “formal accounting” is the logical corrective to “assumptions of benefit” (2016: 184). Frerichs and Lasker have confidence in “good data” to light the dark path forward (not unlike global health itself, which relies on the call for “better metrics!” or “more evidence”—assumed to transcend politics altogether—to reproduce itself). Vincanne Adams’ (2016) edited volume Metrics, however, challenges this confidence by revealing that data and metrics make the world as much as they measure it. The volume isn’t simply a story of how metrics are bad or get things wrong, though; instead, the contributors employ ethnography in sites across the globe to trace the social lives of metrics and to sketch out the worlds and relations they constitute as they come into being, travel, and succeed or fail. Metrics punctures the mystique of numbers and data, which often seem too big to wrap our heads around, despite our blind faith in them.

As Adams suggests in her introduction, global health’s focus on audit, funding, and counting opens a space for metrics; counting has always been central to colonial, state, and transnational projects, but its forms and actors have shifted over time. The entangling of transnational projects of economic development and health has resulted in our ability to recognize “health” only if it can be measured, with implications for the meanings, tempos, and moral economies of care and healing (Adams 2016: 32; McKay 2018). As she points out, “getting the empirical facts needed for metrics may entail a kind of violence to the empirical truths they aim to produce” (2016: 8). Metrics is an effort to escape “database determinism” (ibid.: 46) in order to draw attention to hard-to-measure politico-economic factors that mediate medical care (Taylor-Alexander 2016). Collectively, the authors argue for the utility of anthropological methods in the global health industry: ethnography can reveal that metrics conceal as much as they claim to reveal, capture the things that spill over or fall outside that which can be counted, and show how metrics produce “collateral effects and opportunities” (Adams 2016: 12; see also Nelson 2015). Thus, Metrics is a timely contribution amid the datafication of health and economization of life (Ruckenstein and Schull 2017, Murphy 2017). A growing body of work indicates that the conversion of lives, selves, and relations into quantified data has profound effects on what it means to be human, and becomes entangled with relations, meaning-making, and geographies of inequality. Metrics is a call to preserve the spaces and experiences that exceed numerical data and counting, and to remain committed to methods and representations that might amplify them.

The chapters in Metrics are broad in scope, even as they collectively capture what numbers and metrics do beyond mere counting or miscounting. Claire Wendland and Adeola Oni-Orisan, for example, consider metrics in the realm of maternal mortality in Africa, drawing on ethnographic work in Malawi and Nigeria, respectively. Wendland reveals how metrics—in this case, the maternal mortality ratio (MMR)—are “used as a solid fact” but are in reality “wobbly figure[s]” (Wendland in Adams 2016: 68). Her impressive close readings of the components of daunting equations alongside her ethnographic data demonstrate that numbers are stories that can be as rigorously subjected to critique and analysis as any other text. Oni-Orisan captures the political work that maternal mortality ratios do on the ground, arguing that when numbers become instruments for political mobility and economic advancement, people seek to align themselves with easily quantifiable goals and powerful funding institutions, rather than with locally pressing problems (ibid.:89). Health becomes a set of numbers rather than a lived experience, a claim to fame for a governor or hospital, a form of social mobility, and a way for corporations to gain part of a lucrative funding pie.

In another contribution, Marlee Tichenor analyzes a 2010-2013 “data strike” by Senegalese health worker unions who withheld routine patient data from the Ministry of Health even as they continued to deliver health care. Tichenor reads this strike as a form of political resistance reflective of global health governance in Senegal (Tichenor in Adams 2016: 113), observing that the labor of workers as data-producers gains Senegal admittance into global health markets and enables funds to flow. Molly Hales, meanwhile, draws on ethnographic work with a public health nursing program for the Yup’ik of Alaska to consider how metrics required by funders of behavioral health programs affect delivery of care in Yup’ik communities. While the state of Alaska and the U.S. government fund much of the region’s health care, the funding structures and cycles mimic global health’s short-term grants (Hales in Adams 2016: 131). Amid new kinds of quantitative evaluation criteria for medical or mental health treatment, Yup’ik leaders who run health programs struggle to implement healing practices and interventions that affirm local ontologies and definitions of health, treatment, and care. For the Yup’ik, healthy living cannot be broken down into isolated practices or indicators; data-driven processes inadvertently fragment, rather than enhance, Yup’ik health services.

Susan Erikson argues that in addition to claiming to count or measure, metrics also create value and profit, reconfiguring health in the process. Amid the sense that one can make money doing good things, financial advisors and speculative logics drive global health. Investors need metrics because they are proxies for value; Erikson demonstrates that “metrics make health values correspond to financial values,” (Erikson in Adams 2016: 158) and highlights the risks of conflating health and financial returns (Adams 2013). Her chapter in Metrics considers how shifts in our imaginaries of care and its delivery reflect political economic pressures and reconfigure global (health) institutions (cf. Kenworthy, Thomann, and Parker 2018 on the rebranding of the AIDS epidemic).

In Lily Walkover’s contribution, the absurdities of audit-fever manifest when “grassroots” partners to a U.S.-based nonprofit waste valuable time implementing a survey to see if they are being sufficiently empowered. This anecdote demonstrates a number of things, not least being the way accounting practices associated with operations research and monitoring and evaluation enter local moral economies wherein they may be viewed as insulting or infantilizing. Through her case study, Walkover shows the difficulty inherent in measuring human capacity, and illustrates how donor demand for short term, measurable results limits the scope of possibility for organizations on the ground. Her piece brings to light the perils of the assumption that “only those who can be counted can…be seen as deserving” (Walkover in Adams 2016: 175) and urges us to take pause in the process of measuring or counting to ask: What hierarchies of value or triage logics mediate the question of who or what counts?

Drawing on her research with the Veterans Health Administration in the U.S., Carolyn Smith-Morris reflects on the challenges of bringing qualitative methods and data to bear on conversations in an outcome-driven and politically charged context. Her piece brilliantly illustrates multiple ontologies and renderings of a single clinical trial among veterans with spinal cord injury (cf. Mol 2003, Brives 2013), and shows how the frames and epistemologies utilized by different actors determine what each set of actors “sees.” In her case study, an experimental treatment model was deemed to have been implemented successfully, according to its criteria for fidelity, a metric of scientific rigor. Yet, these metrics provide no real evidence of success in the eyes of an anthropologist (or, likely, participants). Finally, Pierre Minn draws on research with a U.S.-based organization operating health programs in Haiti to reflect on challenges inherent in quantifying alternatives to the medical missions so well known to potential funders. His case study organization’s primary goal of strengthening Haiti’s public health system (a departure from more common models of distributing countable health commodities) requires local buy-in and long-term trust, but metrics falter at measuring such dimensions. Minn pushes us to more deeply interrogate global health’s investment in conclusively arbitrating the success or failure of initiatives.

Metrics is crucial reading for those who eschew and embrace numbers alike. The book would be complemented, however, by a growing body of U.S.-focused scholarship that explicitly considers how technologies of surveillance—including metrics or algorithms—are co-constituted by and rooted in anti-blackness (Browne 2015, Beutin 2017, Noble 2018). The impulse to surveil, to measure, and to count is fundamentally racialized, and many of the kinds of metrics and technologies deployed within the global health and development apparatuses embed the same assumptions of moral bankruptcy, greed, or criminality that have undergirded projects of colonialism, enslavement, and domination in the past and present. Metrics (and biometrics) are deeply entangled in projects of the settler colonial state, too, often mobilized through recourse to the good life, health, or care (Pugliese 2007, Stevenson 2014, Smith 2015). Global health is a formation with origins in quantifying racialized others to better govern them, a legacy that should figure centrally in our theorizations of audit culture, datafication, and the past and present violences wrought by metrics of health, education, and fertility.

From Metrics, we learn that numbers are contingent, partial, placeholders, or performances. It is through the authors’ storytelling that we come to understand what numbers do and undo as they enter into specific social relations and transactions. Taken collectively, the authors in this volume reveal metrics to be what Michelle Murphy terms “phantasmagrams,” or quantitative practices “that are enriched with affect, propagate imaginaries, lure feeling and hence have supernatural effects in surplus of their rational precepts” (2017: 24). It is only by entering into the thick of things, seeing firsthand what numbers do and what people do with numbers, that we might better understand rather than take for granted the buzzwords of global health (Feierman et al 2010, Neely and Nading 2017, Scherz 2018). Ethnography allows us to find the people within systems dominated by metrics and algorithms, to destabilize the dichotomies that uphold easy distinctions between human and data (Seaver 2018). In these fine-grained accounts, readers will be convinced that the kinds of evidence often dismissed as mere stories are in fact foundational to doing good global health.


Global health is many things to many people: aspiration, investment, data production, an opportunity to “do good,” shiny technologies and magic bullets, triumph over pathogens and nature, a site where science and culture clash, and object of suspicion. Scientists, foundations, NGOs, clinicians, politicians, volunteers, and anthropologists become differently entangled within this cat’s cradle. The three texts reviewed here curate stories that complicate and push back on normative triumphalist or optimistic narratives of global health by providing new lenses through which to see familiar phenomena (epidemics, global health volunteering, and the frenetic circulation of numbers in a moment of evidence-based global health). The books also raise questions about the practices, genres, and politics of critique in global health: Anthropologists, for example, are known for being nitpicky naysayers, angling to find failures or shortcomings in even the most well-intentioned of actions. Yet, written from multiple disciplinary perspectives, these texts reveal that critique need not manifest as “giving up on global health” (Hardon and Pool 2016); instead, mobilizing multiple methods and telling different stories to shed light on new slices of global health worlds deflates assumptions that global health and its projects and designs are ever wholly successes or failures, good or bad.

Amid fascination with big data and quick fixes for pressing social and political problems, anthropological and historical approaches to global health are much needed. Anthropological theory, method, data and knowledge are anticipatory technologies with great potential (Erikson 2018:333, see also Abramowitz 2017). Granular engagement with in-the-moment social practices is not just context for global health, but, rather, should be at the core of its designs and intentions. Given the ways that politicians, capitalists, scientists, and bankers in the North have long sought to use people and labor in the Global South as raw materials to produce wealth, history should figure prominently in our analyses of global health events, projects, discourses, and mishaps, and in our efforts to meaningfully decolonize global health, anthropology, and anthropological theory (Horton 2018, Manderson and Levine 2018, Ugwu 2018). The legacies of the Haitian revolution and its aftermath, as I argued above, are crucial to understanding the 2010 cholera epidemic or earthquake. Low death tolls in Gaza, as another example, can only be interpreted when the calculated project of the Israeli state to maim—but not kill—Palestinians and, thereby, to capacitate settler “humanitarianism” is drawn into the analytic frame (Puar 2017).

Finally, while race has come to be seen as an important determinant of health (though here, we might consider how persons in the postcolonial world, particularly Africa, become deracinated in analyses that focus primarily on “culture” or “ethnicity”), it rarely figures as constitutive of definitions of health and the category “human” itself: metrics, technologies, and definitions of expertise or knowledge likewise take Whiteness (and maleness) as the norm or mean (here, anthropologists can learn from a long body of work in black studies; for some recent work, see McKittrick 2014, Jackson 2015). There is an opening here for critical global health scholars to more explicitly consider global health, and health itself, as a racializing assemblage (Weheliye 2014). Given global health’s colloquial and narrow association with the “Global South,” the rise of critical global health studies also presents an opportunity to think from and with perspectives and ways of organizing social life that emerge from communities and actors actively making do, theorizing, and contesting global health’s dominant logics. Ethnography destabilizes portraits of the Global South as merely a network of host communities for Northern scientists or volunteers or a laboratory for Northern experiments. These books—and the broader field of critical global health studies—mobilize diverse methodologies to insist on the possibility of other global healths that take as foundational to their practice, theories, and design the forms of knowledge, histories, power relations, and people currently seen as mere stories or background.

Crystal Biruk, Oberlin College

Reviewed in this Essay

Adams, Vincanne, ed. 2016. Metrics: What Counts in Global Health. Durham, NC: Duke University Press.

Frerichs, Ralph R. 2016. Deadly River: Cholera and Cover-up in Post-Earthquake Haiti. Ithaca, NY: Cornell University Press.

Lasker, Judith. 2016. Hoping to Help: The Promises and Pitfalls of Global Health Volunteering. Ithaca, NY: Cornell University Press.

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[1] Here, I borrow Jemima Pierre’s (2012) definition of “Whiteness” as an “ideology, trope and cultural practice” distinguished from actual racialized White bodies (72).

About Matthew Wolf-Meyer

Matthew Wolf-Meyer is an anthropologist and historian of science and medicine in the United States. He is author of The Slumbering Masses: Sleep, Medicine & Modern American Life (UMN Press, 2012), Theory for the World to Come: Speculative Fiction and Apocalyptic Anthropology (UMN Press, 2019), and Unraveling: Remaking Personhood in a Neurodiverse Age (UMN Press, 2020). He blogs at and

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