The Uncounted: Politics of Data in Global Health, by Sara L. M. Davis (New York: Cambridge University Press, 2020).
Reviewed by Julie Billaud, Graduate Institute in Geneva
Over the past two decades, anthropologists have demonstrated an increasing interest in knowledge production in national and international governance processes. Inspired by the pioneering research of American anthropologist Sally Engle Merry on the spread of indicators in the field of human rights, researchers have examined the dynamics of power/knowledge embedded in these ubiquitous governance technologies and questioned the taken-for-granted correlation between transparency and ‘good governance’ that serves to legitimize the spread of counting, accounting and auditing mechanisms. A very wide range of anthropologists including Andrea Ballestero, Kregg Hetherington, Christina Garsten and Kerstin Jacobsson, as well as those like Cris Shore or Andrew Kipnis who have extended the study of “audit cultures” as defined by Marilyn Strathern, have highlighted how monitoring techniques that primarily rely on quantitative methods reveal certain truths while concealing others, oversimplify inherently complex social realities, overlook local forms of knowledge, relegate the responsibility for compliance to the monitored institutions, entrench power asymmetries and subtly discipline auditees into doing what counts instead of relying on their own appreciation of what really matters in their field of action.
Obviously, global health governance has not remained immune to the quiet power of quantification. As has been discussed by Vincanne Adams and Cal Biruk, the quest for “clean,” “reliable,” or high-quality and granular statistics has been a central concern of the various actors involved in international efforts to eradicate HIV/AIDS. Under the pressure to improve cost-effectiveness, measure impact and provide strong evidence to justify programs and policies, global aid agencies increasingly rely on indicators and measurements to rationalize their response and prioritize their interventions.
The Uncounted brings an important contribution to these timely debates, adding the perspective of an anthropologist, human rights activist and global health consultant with long experience of engagement in the field. This positionality partly explains the “cautious optimism” (p. 39) Davis manifests in her writing. Indeed, while remaining concerned with the many limitations of quantitative methods for providing accurate representations, she also finds hope and inspiration in the energy deployed by local activists who advocate for greater inclusion in decision-making and data production processes. Bringing nuance to the critical study of data in global health, a field in which qualitative research is often situated as a form of counterevidence to metrics, Davis rightly emphasizes that “all communicative signs are abstractions, whether numerical or verbal. … All forms of knowledge are partial and emergent” (p. 39). While anthropological knowledge is particularly useful for detecting the historical and social specificities that quantitative research can miss, indicators can also play a crucial political role in making visible segments of populations that are most affected by HIV and in greatest need of health services. In the hands of activists, indicators can therefore be used as advocacy tools to press for change, and their efficacy can be rethought through such efforts to influence important decisions on who counts, who does the counting, and who gets counted. The book documents this fierce battle for recognition, while exposing the real dangers faced by so-called key populations (sex workers, men having sex with men, drug users) for whom invisibility also represents a survival strategy.
The book is wide in scope and deep in breadth. Readers should prepare themselves for a deep dive into the technicalities of data production. Davis examines in great detail the mathematical models informing cost-effectiveness analysis—a key part of the neoliberal structuring of aid provision that she studies—as well as the questionnaires designed by international health experts, civil society activists and government officials to estimate the size of key populations and the interlocking set of indicators and rules used by the Global Health Fund to decide on eligibility for aid and intervention. She zooms in the main centers where global health policies are discussed, such as the meeting rooms of the Global Fund or the offices of UNAIDS and WHO experts in Geneva as well as the International Conferences on HIV Science in Paris. She then brings us to informal meetings with civil society representatives where narrative strategies are devised, and on her multiple journeys to the Caribbean where she follows and participates in an NGO-led survey across six countries. The details are overwhelming at times, even though they offer illuminating insights on how HIV diplomacy is carried out at the international, regional and local levels.
Most importantly, Davis deftly conveys the atmosphere of emergency within which the struggle for data takes place. She has a real talent for keeping the reader on her toes: Will the “rule of rescue” (p. 170) that guides the global AIDS movement prevail over the principles of cost-effectiveness upheld by funding institutions? Will civil society representatives succeed in negotiating alternative indicators to determine the Global Fund’s eligibility criteria? Will they manage to quantify, and hence put on donors’ radar, the problem of intimate partner violence that prevents women from disclosing their HIV status? The many tensions and paradoxes triggered by the race to “end AIDS”—a goal she puts under analysis as well (p. 20)—are explored through evocative ethnographic vignettes that render remote and abstract policy tools more concrete and tangible. The Uncounted offers an important window into AIDS governance, opening up ways to study power and the construction of regimes of truth that shape our contemporary world. It should become a must-read book for those academics and activists willing to get their head around the system of AIDS knowledge as well as the social and semantic spaces and new sets of relations that it sets in motion.