Saúde e Sociedade ISSN: 0104-1290 [email protected] Universidade de São Paulo Brasil
Biehl, João; Petryna, Adriana Peopling Global Health Saúde e Sociedade, vol. 23, núm. 2, abril-junio, 2014, pp. 376-389 Universidade de São Paulo São Paulo, Brasil
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João Biehl Abstract PhD in Anthropology. Susan Dod Brown Professor of Anthropo- logy and Co-director of the Global Health Program at Princeton The field of Global Health brings together a vastly University. diverse array of actors working to address pressing Address: 128 Aaron Burr Hall, Department of Anthropology, Prin- health issues worldwide with unprecedented finan- ceton University, 08544, Princeton, NJ, USA. E-mail: [email protected] cial and technological resources and informed by various agendas. While Global Health initiatives Adriana Petryna are booming and displacing earlier framings of the PhD in Anthropology. Edmund J. and Louise W. Kahn Term Professor field (such as tropical medicine or international of Anthropology at the University of Pennsylvania. Address: 3260 South Street, Department of Anthropology, Uni- health), critical analyses of the social, political, and versity of Pennsylvania School of Arts and Sciences, 19104-6398, economic processes associated with this expanding Philadelphia, PA, USA. field — an “open source anarchy” on the ground — are E-mail: [email protected] still few and far between. In this essay, we contend that, among the powerful players of Global Health, the supposed beneficiaries of interventions are ge- nerally lost from view and appear as having little to say or nothing to contribute. We make the case for a more comprehensive and people-centered approach and demonstrate the crucial role of ethnography as an empirical lantern in Global Health. By shifting the emphasis from diseases to people and environ- ments, and from trickle-down access to equality, we have the opportunity to set a humane agenda that both realistically confronts challenges and expands our vision of the future of global communities. Keywords: Global Health; Political Economy; Evidence Making; Pharmaceuticalization; Social Change; Human Values; Fieldwork; Medical Anthropology.
376 Saúde Soc. São Paulo, v.23, n.2, p.376-389, 2014 DOI 10.1590/S0104-12902014000200003 Resumo Introduction O campo da saúde global articula um diversificado The field of “Global Health” brings together a vastly leque de atores que trabalham para resolver pro- diverse array of actors and interests and it has blemas prementes de saúde em todo o mundo, com become, in the words of economist Angus Deaton, recursos financeiros e tecnológicos sem precedentes “a big business” (Deaton, 2013; Brown, et al., 2006; e munidos de agendas das mais variadas. Apesar Cohen, 2006; Fassin, 2012). The World Health das iniciativas em saúde global estarem crescendo Organization, the World Bank, the Gates Founda- de forma expressiva e deslocando enquadramentos tion, pharmaceutical companies, governments, anteriores do campo (como a medicina tropical ou universities and innumerable nongovernmental saúde internacional), as análises críticas dos pro- organizations are all working to address pressing cessos sociais, políticos e econômicos associados a health issues worldwide with unprecedented finan- essa expansão ainda são escassas. Neste artigo sus- cial and technological resources and informed by tentamos, a partir de uma perspectiva que leva em various agendas. While Global Health initiatives conta os sujeitos, que o campo da saúde global é uma are booming and displacing earlier framings of the “anarquia de código aberto”. Em geral, perdem-se de field (such as “tropical medicine” or “international vista os supostos beneficiários das intervenções, health”), critical analyses of the social, political, and que aparecem como tendo pouco a dizer e nada a economic processes associated with this quickly contribuir. Argumentamos por uma abordagem mais evolving field — an “open source anarchy on the abrangente e centrada nas pessoas, demonstrando o ground — are still few and far between. papel crucial da etnografia como lanterna empírica In this essay we contend that, among the power- na saúde global. Ao mudar a ênfase das doenças às ful interests of Global Health, the supposed ben- pessoas e seus contextos e do acesso de cima para eficiaries of interventions are generally lost from baixo para a equidade, temos a oportunidade de view and appear as having little to say or nothing definir uma agenda humana que simultaneamente to contribute. While there have been efforts to confronta realisticamente os desafios que enfren- engage civil society and activists, especially in tamos e expande nossa visão sobre o futuro das the response to HIV/AIDS, there continues to be comunidades globais. a strong biomedical orientation which sees civil Palavras-chave: Saúde Global; Economia Política; society engagement as politically necessary but Produção de Evidências; Farmaceuticalização; Mu- “scientifically” irrelevant. In other words, with the dança Social; Valores Humanos; Trabalho de Campo; hope of a biomedical magic bullet reigning, the Antropologia Médica. power of “data” defined in biomedical terms, the vi- sion of technocrats tends to outweigh other forms of data and evidence. We make the case for a more comprehensive and people-centered approach and demonstrate the crucial role of ethnography as an empirical lantern in Global Health. The stories and ideas we present come from close readings of the Global Health literature and our teaching of Medical Anthropology and Global Health courses. We also learn a great deal from the archival work of medical historians and the field studies of anthropologists seeking to understand the impact of Global Health interventions on health systems, go vernance, and citizenship. Our independent research projects with marginalized communities dealing with treatment access for HIV/AIDS and psychiatric care (Biehl, 2005, 2007) and on the globalization of
Saúde Soc. São Paulo, v.23, n.2, p.376-389, 2014 377 clinical trials (Petryna, 2009; Petryna et al., 2006) Changing public health contexts have been critical to our understanding of social and political determinants of disease and health. We In the course of the twentieth century, innovations draw lessons from our co-edited book, When People in public health and medicine helped to increase Come First: Critical Studies in Global Health, which life expectancy at birth by almost thirty years in gathers vivid case studies focusing on the themes the United States and in other developed countries. of evidence, interventions and markets in Global Meanwhile, mortality rates remained high and life Health (Biehl and Petryna 2013). expectancies short in poor countries (Cutler et al., When using the term “critical” we have in mind 2006). Advances in medical technology continue to Michel Foucault’s essay “What Is Critique?” Critique, give cause for hope, as does the substantial increase he wrote, is a certain way of thinking, speaking and in financial resources now available to address some acting: “a certain relationship to what exists, to what of the world’s most pressing health challenges. New one knows, a relationship to society, to culture, and state policies, public-private partnerships, and mul- also a relationship to others” (Foucault, 1997, p. 42). tidisciplinary research collaborations are reshaping As such critique is “the art of not being governed the field of Global Health and, in the process, putting quite so much” (p. 45). But critical thinking also older paradigms into question and transforming re- entails imagining and desiring that things might alities on the ground. In key developing democracies be otherwise: “Critique only exists in relation to — such as Brazil, India, and South Africa — we see something other than itself [...] it is an instrument, activists and patients engaged in struggles over ac- a means for a future or a truth that it will not know cess to high-quality care and, at a more fundamental nor happen to be” (p. 42). level, debating the meaning, object and implications Critical thinking seeks epistemological break- of health conceived as a right rather than a privilege throughs. Such breakthroughs however do not or commodity (Biehl et al., 2012; Fassin, 2007). belong to experts and analysts alone. The unpredict- Consider the story of Janira who lies in bed at able and cumulative experiences of people navigat- home while her mother, Carmen, visits the public ing Global Health and humanitarian interventions defender’s office in Porto Alegre, Brazil. Carmen and their aftermaths, we argue, can also produce is filing a lawsuit to obtain the medicine that her breakthroughs that demand recognition. People’s daughter urgently needs to treat severe pulmonary practical knowledge compels us to leave comfort- hypertension. A heart attack the year before led to able disciplinary silos and to think of them not just a loss of mobility, and Janira has not been able to as problems or victims, or patients or, worse, as resume work. Her doctor has prescribed six medi- vectors or disease carriers, but as complex agents cines; five are provided through Brazilian Unified with sometimes competing interests about the Health System (SUS), while the Brazilian sixth, a value of health and the meaning of wellbeing. That high-cost vasodilator, is not. The doctor advised the knowledge can also help us to better understand low income family to seek free legal assistance at how larger systems and policies shape life chances the public defender’s office. locally, while at the same time keeping our attention Carmen hands the doctor’s prescription to the to panoramas in flux. People on the ground recog- attorney Paula Pinto de Souza responsible for her nize what is troubling them and it is somewhere in case. Is it here that I get the medicine? she asks. the middle of social lives that the work of critique Souza welcomes Carmen to the juridical hospital, always begins. As ethnographers, we are uniquely but she explains that getting the medicine will not positioned to see what more categorically minded be so simple. As a legal advocate for the poor and experts may overlook: namely, the empirical evi- chronically ill, Souza’s job is to ameliorate suffering dence that emerges when people express their most and to restore the rights of her clients. The person, pressing and ordinary concerns, which then open she explains, comes here sick and wronged by the up to complex human stories in time and space and failure of public policies. We are beyond preventive that must become the center of public reflection medicine here and the concept of health as physi- and action. cal, mental and social wellbeing is no more. When
378 Saúde Soc. São Paulo, v.23, n.2, p.376-389, 2014 this infirmed person comes to me, the cure is most family went into debt and judicialization became a likely no longer possible. Her right to health has last resort. The public health system was now finally been profoundly injured by public power. Given the working for Janira, but could it work fast enough severity of Janira’s condition, Souza will ask the to save her? district judge to issue a court injunction compelling Attorney Paula Pinto de Souza considers the the state to provide Janira’s treatment right away. costs of lawsuits for treatment to the state to be Carmen, whose husband died of cancer, is re- negligible when compared to the scope of unrec- tired and lives on a small pension. Her home is a ognized patients’ needs, but critics allege the judi- one-room shack on the outskirts of the city, which cialization of health makes the health system less she shares with her daughter and two granddaugh- efficient and more unequal overall (Ferraz, 2009; ters. A monthly course of the vasodilator Janira Yamin and Gloppen, 2011). Janira and Carmen do not needs costs about US$1,000. Carmen has been invoke rights and for them it does not matter if the purchasing the medicine in small amounts with life-extending medicine comes from the medical or borrowed cash, indebting herself to members of the juridical hospital, as long as it comes. They are her extended family. At the same time, Carmen desperate but also resourceful and determined in complains that she has already gone to the state their efforts. In their fight for life, they attempt to pharmacy several times to obtain the five other maintain healthy bodies but also healthy relation- medicines that Janira needs, and that should be ships and households. publicly available, but they are always out of stock. Indeed, the story of Janira and her family efforts She makes a little extra money performing Afro- is not unique. It reflects how broader questions of Brazilian rituals in her home and occasionally access to technology and social justice are playing receives a food basket from her religious organi- out in today’s rapidly changing public health con- zation. When we visited the family, we noticed an texts. Fieldwork or home visits such as the one we offering to the orixás filled with packaged sweets. have described can vividly capture these realities I do this so that all patients who need medicines in flux. Accounts based on the experiences of real win their lawsuits, Carmen explains. people — stories that are often obscured by abstract What Janira really needs is a heart transplant, and bureaucratic considerations of public policy and all the medicines she takes are meant to keep — are essential to comprehending the collision of her healthy enough to undergo the surgery. Janira’s a crushing burden of disease with emerging audit brother, who lives in another shack on the same lot cultures and the new therapeutic regimes in which with his own family, routinely checks the status of life chances unfold. Such accounts also point to the her case at a nearby Internet cafe. Within days of the need for comprehensive care in Global Health and public defender’s filing, the district judge issued an how it can be crafted. injunction for the medicine to be delivered to Janira. In what follows, we explore the concrete and Two months later it still had not arrived. unexpected effects of Global Health interventions, When we returned a year later, Janira said that taking as case studies the magic bullet attempt she was receiving the medication as a result of the to eradicate malaria in Mexico, the public-private injunction. The year before she could hardly get up treatment rollouts in Uganda and Mozambique, by herself to go to the bathroom, and now she could and the impact of evidence-based medicine in the help with house chores. She began to cry when she design and implementation of public health inter- said that she could now take her daughters to school, ventions in Nepal and post-Katrina New Orleans. which gave her immense pleasure. We argue that ethnographic evidence is essential At a time of great medical progress and amid for re-envisioning care and implementing different Brazil’s economic boom, Janira is barely clinging to plans of action. The very concept of failure and of life. As she waited for her condition to improve to be what counts as meaningful evidence of a successful able to qualify for a possible heart transplant, the intervention must also be scrutinized.
Saúde Soc. São Paulo, v.23, n.2, p.376-389, 2014 379 Through and beyond the magic they conceived their roles to be those of listeners and cultural brokers. Beyond the underestimated bullet approach language barrier, their report noted many compli- When we look at international health interven- cations with respect to the program and why it was tions historically, it becomes clear that the politi- not achieving its anticipated success. For example, cal and economic requirements of the day and the the medical anthropologists explored complex ideological whims of the elites in charge determine rotational housing patterns linked to seasonality, how priorities are set and why they are abandoned. which meant families abandoned houses that had As social scientists unearth the recent history that been sprayed or preferred to simply sleep outside explains how people become target populations in in the heat of the summer. More fundamentally, Global Health, unanticipated anthropological ter- indigenous communities often employed their own rains come into view: we find ourselves face-to-face healing systems and understandings of fever that co- with profound disconnections between campaign existed uneasily with the public health information designs and intentions and the complex ways in that government agents circulated about malaria. which those campaigns are actually received and And, as the medical anthropologists would point critiqued. The counter-knowledge of the people who out, underpinning this environment of suspicion are at the center of interventions is thus integral to were fundamental differences in health priorities. In assessing their actual impacts and to mitigating many communities, malaria was not conceived of as against blind spots and repetitions of history. a major health problem or even as a single disease, In his book Cold War, Deadly Fevers, historian and many people in rural areas wondered why it was Marcos Cueto (Cueto, 2007) documents the story being singled out when other more pressing health behind the Malaria Eradication Program that played concerns were being ignored. a crucial role in Mexico’s public health policy during This collision between local values and interna- the politically charged years of the Cold War era. tional public health agendas was hardly just a fluke While constantly keeping in view the campaign’s or footnote in the history of malaria eradication: international political implications, Cueto’s detailed Cueto’s complex portrait captures the fact that it account of the way the eradication campaign unfold- was a key reason for the campaign’s ultimate failure. ed in different locales leads him to document how Without paying attention to how this intervention the Rockefeller Foundation and elite national health became embedded in local economies and politics, experts campaign designs clashed with indigenous national health officials often treated social resis- understandings. For example, many families living tance as a “communications problem” in a popula- in rural Mexican communities simply refused to tion in need of education rather than as a problem let the DDT sprayers into their homes. Cueto found of the design of the intervention itself. cases of spontaneous protest escalating to armed The implications of these realities run deep for conflict. After the first several years, even people our health policies today. In 2007, the Gates Founda- who had complied with earlier rounds of DDT spray- tion revived the failed malaria campaign, pledging ing angrily noted that it worked less effectively every to eradicate the disease from the world (Cueto, 2013). time, and that many insects seemed to be developing A year earlier, the World Health Organization once resistance and growing bigger instead of dying off. again approved the spraying of houses as an appro- In this charged historical moment, medical an- priate part of malaria eradication. As Cueto notes, thropology emerged as an applied social science. An- pyrethroid-soaked bednets and pharmaceuticals thropologist Isabel Kelly, a former student of George have become the technical fixes of a supposedly Foster at Berkeley, began collaborating with Héctor “new era” of magic-bullet approaches. Four decades García Manzanedo and the Mexican Health Secre- after its original failure was declared in 1969, the tariat on rural projects in 1953. As the pair began goal of malaria eradication is now resurrected. researching how the malaria eradication program The fact is that the magic-bullet approach — the was being received by indigenous communities, delivery of health technologies (usually new drugs
380 Saúde Soc. São Paulo, v.23, n.2, p.376-389, 2014 or devices) that target one specific disease without of real people dealing with insecurities of all kinds regard to the myriad societal, political, and eco- find their way into and improve current practices nomic factors that influence outcomes — has been in Global Health? the norm in international health interventions for decades (Birn, 2005; Enserink, 2010; Stepan, 2011). Projectified landscapes of care There are, however, significant practical and episte- mological downsides to this approach, which is now In the twentieth century, international health ini- being challenged. Social scientists and health policy tiatives were by and large implemented by states, advocates caution that a narrow focus on the triad subject to the coordination of specialized bodies of technology delivery, patient compliance, and the such as the World Health Organization (WHO). In basic science of disease, as important as these are, this paradigm, the main source of authority was the is insufficient. Also, unintended consequences may state, which took the lead in setting priorities and be unleashed by even the most carefully designed allocating resources. The politics of international interventions (Larson, 2011). health care were, as a result, subject to the usual The Global Health community has overempha- constraints of diplomacy (Fidler, 2007), while the sized individual risk factors that ignore how health WHO and related bodies played a coordinating role, risks are shaped by law, politics, and practices rang- often using the discourse of human rights to ori- ing from industrial and agricultural policies to dis- ent and instigate efforts. These dynamics would be crimination, violence, and lack of access to justice. somewhat altered in the context of the United Na- We need to better attend to breakdowns in public tions Millennium Development Goals (MDGs), which health systems and to the many political and social recognized health as an essential value and as a key determinants of health (such as education, water, pillar of development (United Nations, 2000). New sanitation, vector control, air pollution, and accident forms of cooperation and intervention were estab- prevention) that make people vulnerable to disease lished to reach the targets of reducing maternal and and injury in the first place (Amon and Kasambala, child mortality and expanding access to treatment 2009; Farmer, 2004; Freedman, 2005). Given the for infectious diseases, for example. In the process, extreme inequalities that are so intricately woven the interests and practices of the private sector into the current international order as well as into began to play a larger role in global public health. the social and political fabrics of countries and re- Humanitarian schemes and health system building gions (Deaton, 2013), we need integrated approaches have made common cause with the technical and that recognize the profound interdependence of financial know-how of the private sector. health, economic development, good governance, We now see a multiplicity of actors, all vying and human rights. Any sustainable development has for resources and influence in the political field of to reach and improve the conditions of the poorest Global Health, each seeking to remain a relevant and and most vulnerable groups carrying the highest powerful player. Ranging from the Gates Foundation burdens of compromised health. Moreover, as is to pharmaceutical company drug donation programs evident in Janira’s case, disease is never just one and PEPFAR (the [US] President’s Emergency Plan thing, technology delivery does not translate into for AIDS Relief), to research initiatives, South-South patient care, and biology and technology interact cooperation and myriad rights-based pilot projects, in ways we cannot always predict. these diverse interests are setting new norms for So, we must ask: What really happens when institutional response, sometimes providing the new treatments are introduced into epidemiologi- public health resources that states and markets can- cally diverse and variable social worlds? How is care not or have failed to furnish. Locally, such multiple organized by providers, and by state and nongov- and fragmentary Global Health interventions con- ernmental organizations? By what trajectories and solidate what anthropologist Susan Reynolds Whyte means do the people who desperately need care ac- and colleagues (Whyte et al., 2013) in Denmark and cess it (or fail to access it)? And how can the stories Uganda call “projectified” landscapes of care.
Saúde Soc. São Paulo, v.23, n.2, p.376-389, 2014 381 The Ugandan health system, at least as it re- exclusively as patients or as outcomes or failures lates to HIV/AIDS, is almost exclusively dependent of interventions, but rather as embedded actors on international aid projects. After the civil war, moving within complicated social networks. This Uganda’s government seized on health interventions analysis provides a point of entry to assess the to bolster its legitimacy abroad and at home. This micropolitics in which health and health care are welcoming attitude wins the Ugandan government brokered, accessed, and transformed — and it gives a place in the world of international politics, as us openings to think of ways to include those who it demonstrates at once a willingness to lift itself have been left out. from its ruinous recent history and, perhaps more importantly, to comply with neoliberal norms of Global Health as open-source state intervention. At home, the introduction of international actors provides much-needed relief anarchy to people living with HIV/AIDS and their families, There is considerable confusion about how old and and enables the government to present itself as at new players and initiatives fit together in a Global least partially providing health care to its populace. Health architecture, and how they inform the ongo- In their longitudinal fieldwork with the first ing debate about whether such architecture can and generation of AIDS patients who has had access to should be constructed and, if so, by whom and in antiretroviral therapies and thus to a second chance whose interest (Cohen, 2006; Frenk, 2010; Keusch at life, Reynolds Whyte and colleagues describe et al., 2010). In practice the concerns of donors, not those who benefit from these health initiatives as recipients, tend to predominate (Easterly, 2006; Ep- “clients,” a felicitous term that can be understood stein, 2007; Ramiah and Reich, 2005; Farmer, 2011). in both contrasting and complementary senses. Often, donors insist on funding disease-specific One, which harks back to Uganda’s political past, and technologically oriented vertical programs at points to the ways in which these persons, who enjoy the expense of the public sector. And, whatever little power or resources other than those afforded differences in interest and ideology may divide through social networking, must seek out patrons corporate, activist, and state public health agendas, better positioned within the world of health care the imperatives of “saving lives” and “increasing in order to gain access for themselves. The other access” seem to reconcile these differences and fold meaning of “client” echoes neoliberal trends which them into an ethos of collective responsibility in the inform much of Global Health investment, and refers face of “crisis.” Global Health players can become to persons as clients or consumers of a product (in impervious to critique as they identify emergencies, this case heath care), thereby establishing a con- cite dire statistics, and act on their essential duty tractual obligation between them and the providers of promoting health in the name of “humanitarian of the product. reason” or as an instrument of economic develop- Here health is not a “right” available to all ment, diplomacy, or national security (Fassin, 2011; citizens, but a service or thing available to those Adams et al., 2008; Buss and Ferreira, 2010; Lakoff in the know and well-connected. “Good” clients are and Collier, 2008; Ventura, 2013). expected to be faithful to their programs and to help Despite the deluge of monies and organizations foster their growth. This “therapeutic clientship” flowing into resource poor settings worldwide, local becomes a support mechanism that extends well- health systems continue to be woefully inadequate. beyond the medical including possible employment, We are also left with an “open-source anarchy” food access, and educational demands. An economy (Fidler, 2007) around Global Health problems — a of loyalties and of financial, institutional, and medi- policy space in which new strategies, rules, distribu- cal sustenance is thus created. This “therapeutic tive schemes, and the practical ethics of health care clientship” stands in for citizenship and governance. are being assembled, experimented with, and impro- The ethnographic analysis of Reynolds Whyte and vised by a wide array of deeply unequal stakeholders. colleagues offers a way to approach persons not The anthropologist James Pfeiffer (Pfeiffer, 2013)
382 Saúde Soc. São Paulo, v.23, n.2, p.376-389, 2014 cuts an ethnographic path through the system of to the impact of structural and economic factors on health care that has emerged in postsocialist, de- treatment and disease. Second, certain statistical mocratizing Mozambique and after the arrival of and quantitative data can be productively reconciled the US President’s Emergency Plan for AIDS Relief with qualitative ethnographic approaches. “Lost to (PEPFAR) aid. The result of the divestment in the follow up,” for example, is not just a metric for judg- public sector is the creation of a fractured and ing the success or failure of a given intervention. uneven health system; state-of-the-art facilities for Instead it is a starting point for looking beyond HIV/AIDS testing and treatment now coexist with the limits such an evaluation imposes and into the all-but-dilapidated state hospitals where wealthy reality of other factors (national economic systems donors create showcase clinics in one region while and infrastructure, for instance) on the lives of the the clinics in a neighboring region atrophy and their HIV-positive. Ethnographic evidence can provide long-term sustainability is always in question. In new ways of looking at care and accountability; it this makeshift system, the Global Health focus is can be put to use in developing different plans of always at the level of the clinic, where interventions action such as those carried out by Pfeiffer and can be followed and their results measured. At- Health Alliance International on the strengthening tempts to make assessments at a national level are of primary care in Mozambique’s health care system. left by the wayside and the myriad social factors that can contribute to positive health outcomes are by Metrics and values and large ignored (or, if acknowledged, not acted on). Moreover, health workers are also in short supply Treatment access is one of the central tenets of Glob- outside spheres dominated by NGOs as limits are set al Health activism and a professed goal of interven- on wages at public institutions and because NGOs tions. Biological and medical sciences have greatly can afford to pay more for specialized services. contributed to today’s therapeutic armamentarium, Pfeiffer also shows how a poor national infra- and the metrics of epidemiology and pharmacology structure and terrible economic hardships intersect have productively shaped the design and implemen- with everyday patterns of sociality to hinder HIV/ tation of interventions. Amid fluctuations in fund- AIDS treatment adherence, especially among preg- ing, the field of Global Health has been consistently nant women. Pregnant women are at higher risk of driven by scientifically based schemes of evaluation being “lost to follow up” (LTFU) because they must revolving around natural experiments, randomized confront a number of unique restrictions and risk- controlled trials (RCTs), and statistical significance laden choices that make treatment access perilous (Hammer and Berman, 1995; Anand and Hanson, and adherence highly problematic. Faced with hun- 1997; Duflo and Kremer, 2008). In this dominant ger, difficulties in accessing treatment, the severe regime of veridiction, evidence-based medicine has side effects of medication, and the stigma associated migrated to the realm of health interventions and with AIDS, too many pregnant women drop out of has quickly positioned itself as the default language programs. for both public and private-sector actors concerned Pfeiffer’s work draws attention to two important with identifying problems and measuring outcomes facets of a critical ethnography of Global Health. (Deaton, 2010; Cartwright, 2011). First, ethnographic accounts allow for a telling Anthropologist Vincanne Adams (Adams, 2013) juxtaposition of scales (ranging spatially, from studied a resiliency-training program for school- the perspective of the patient and the community, age children in New Orleans and a safe-motherhood to a much broader view that reveals the systemic training program for Tibetan health workers. Both flaws of the international financial impositions in programs required health workers to participate in Mozambique; and temporally, from the country’s the new and unfamiliar economy of information on socialist past to its market-fundamentalist present). which the legitimacy of the programs rested. And, Ethnography lays bare how interventions are woven in both cases, the demands imposed by the now-pre- into larger spheres of political economy and points dominant evidence-based medicine approach trans-
Saúde Soc. São Paulo, v.23, n.2, p.376-389, 2014 383 formed not only the evaluation of the interventions, our capacity to apprehend heterogeneity are compro- but also their methodologies, goals, and subjects. mised. Moreover, biosocial approaches to disease The New Orleans program could only be deemed and health that could help to specify dynamic causal reliable, credible and ultimately fundable through connections and local politics are relegated to the the acquisition of privately produced and interna- low-authority category of “soft science” (Adams, tionally standardized assessment tools. In Tibet, 2013; Krieger, 2011). the original project had to be radically altered on Consider the widely cited study by economists Kre- statistical grounds: it was not possible to determine mer and Miguel (2007) on curing worm infections in whether the intervention was more effective than rural Kenya. Kremer and Miguel found that treating chance because “not enough women” died. Following Kenyan schoolchildren with extremely cheap deworm- the advice of a Maryland research consortium, the ing medication increased their school attendance program — now upgraded to a “study” — was made by roughly 10 percent. A New York Times op-ed piece “more scientific” and more globally comparable by heralded the study as “landmark” (Kristof, 2007): with abandoning training in safe motherhood and focus- just a bit of cheap medication, poor countries could ing instead on infant mortality for which “better increase school attendance by leaps and bounds. numbers” were available. Given the affordability and stunning success of the The advent of for-profit institutions as purveyors treatment, many commentators suspected that fami- of services (be it the fulfillment of specialized func- lies who had not benefited from treatment during the tions or an entire intervention) has demanded the study would very happily adopt this new technology. incorporation of systematic economic assessment But Kremer and Miguel (2007) observed a puz- techniques, of which the cost-benefit analysis and zling turn of events after the trial ended and when the audit are the most salient. In this new landscape they followed a group of families outside the original of Global Health saturated with NGOs and special- cohort. Families who were friendly with families in interest groups, there is a movement toward mak- the deworming treatment group were less likely to ing interventions cost-effective and scalable. Thus, treat their children than those who were friendly interventions themselves become producers and with families in the control group. They were also consumers of marketable and comparable informa- less likely to deem the medication effective at im- tion. Entrepreneurship over capitalizable data has proving health. If deworming medicine is the pana- taken hold. cea for anemia and school truancy, then why were As Adams’s study shows, this new landscape of better informed families not treating their children? evaluation is displacing the previous goals of inter- Miguel and Kremer (2008) do not pinpoint the ventions, making the purveyance of actual health reason for the negative effect of this word-of-mouth. services secondary to the development of reliable But they conjecture that the power of communica- methodologies, the generation of comparable data, tion networks and people’s own understanding and the training of a workforce capable of deploy- of worms as a social disease (not predicted in the ing interventions with similar results at a later study design) might have been at play. We have once date. Abandoned in this move are the experiences again a case in which interpersonal relations and of the nominal targets of interventions. The focus the needs and concerns of people on the ground, is no longer on the sick and their caregivers, nor as well as their own sense of the complex ecology is much consideration given to the long-standing of disease, health, and medical technology, elude effects of programs on the lives of people and on controlled studies. With its strict methodological public institutions. imperatives, Global Health expertise often sacrifices RCTs have been given a free pass in the name of the ethnographic evidence or counter-knowledge rigor, economist Angus Deaton argues. But there are that is available as experiments and interventions no magic bullets and there are no gold standards (ever more closely linked) unfold — at the expense (Deaton, 2012). With the hegemony of theoretical of better understanding and, ultimately, more mean- and technical fixes, the kinds of data we collect and ingful and long-lasting outcomes.
384 Saúde Soc. São Paulo, v.23, n.2, p.376-389, 2014 The unpredictable social is not just an obstacle access to treatments and toward delivering value to or a means for perfecting theoretical tools and ex- for patients (Kim et al., 2010). The former goal as- perimental strategies. Questions of how to account sumes a consumer-patient capable of seeking out for persons in the context of their homes and rela- and paying for appropriate treatment as long as it tionships, and of how to involve local communities is available; the latter puts greater responsibility on in the very design and implementation of feasible health systems and providers for actively reaching (rather than technology-enamored) interventions, the patient in need and attending to the full cycle pose continuous political, medical, and ethical of care and health outcomes for his or her medical challenges. With international and national health condition. The focus must be on the results obtained policy’s success largely framed in terms of provid- by the patients (measured in survival rates and in ing and tallying the best medicines and newest the degree and sustainability of recovery) and not on technology delivered, what space remains for the a program’s success (measured, for example, by its development of low-tech or non-tech solutions (such compliance with standardized guidelines or by the as the provision of clean water) and the strengthen- number of drugs distributed). ing of local health systems and prevention efforts A more holistic understanding of health is indeed that could prove more sustainable than high-tech needed and diverse disciplines (including anthropol- solutions alone? How can we escape the dystopic ogy) must be engaged as we seek to understand the futures that are inscribed in present pragmatics? complexities of the context and content of health interventions as well as the trials and errors of real Care people in specific circumstances trying to figure out what works for them. Multi-scale empirical knowl- Technocratic approaches (many times beholden to edge of their efforts is crucial to the development evidence-based medicine) can perpetuate limited un- of a patient-centered care delivery framework. This derstandings of narrowly conceptualized problems alternative knowledge can and should challenge and support a rhetoric that offers only temporary the reductionist epistemic frameworks that tend to control over isolated aspects of a given disease — a inform donors’ priorities and funding decisions as rhetoric that is aligned with the demands of funding well as Global Health evaluation schemes. Moreover, organizations for immediate technical solutions. a people-centered science of care delivery cannot The obsession with scientific and economic pragma- fully flourish without it being grounded in a respect tism results in less attention to the social dynamics for human rights and structures of accountability of programs and can lead to erroneous assumptions and government obligation. about generalizabilty, ie. that particular interven- Anthropologist-physician Paul Farmer (Farmer, tions will work across countries and situations 2004, 2011) is one of the most prominent proponents despite the fact that each will have distinct institu- of a community-based equity approach that blends tions, practices, and rationalities, stubborn deficits, technological intervention with a focus on making and persistent inequalities that will undercut the health systems work. Farmer and Partners In Health powers of overvalued magic bullets. (PIH), the organization he cofounded, understand Global Health, according to business scholar diseases as loci where biology, environment, and Michael E. Porter, mirrors the limitations of health medicine have gone awry; their concept of account- care delivery in the United States and “is stuck in ability and intervention accordingly tackles the an access and volume mindset, rather than focusing structural conditions that perpetuate disease at the on the value delivered to patients” (Porter, 2009, local level. In the interest of making the best care 2010). That is, narrow measurements of efficacy available to the poorest, Farmer and his colleagues concentrate exclusively on the vertical intervention reject economic orthodoxies such as demands for level and can assess only discrete preventative steps, structural adjustments to eliminate health and drugs, or services. Porter and his colleagues call for education expenditures in the name of development, a shifting of the goal posts, away from increasing cost-effective benchmarks that limit the provision of
Saúde Soc. São Paulo, v.23, n.2, p.376-389, 2014 385 wraparound services, and human rights discourses As showed in the field examples from Brazil, that privilege political over socioeconomic rights Mexico, Uganda and Mozambique, disease is multi- (Farmer, 2008; Pfeiffer and Chapman, 2010). layered and multiply determined, people are plural In Partners In Health’s social justice approach, beings and not reducible to populations, and local accounting for individual patient trajectories and realities still very much frame, constrain, and orient staying with patients throughout the course of their interventions. The agency of local actors is not lim- disease and rehabilitation (through the work of lo- ited to their blind acceptance or refusal of whatever cal accompagnateurs) is as important as tackling form of knowledge, technology, or care is provided the economic and social factors that impact families extralocally. Rather, people’s agency is bound to and mitigating the decay of clinical infrastructures. preexisting forms of exchange, politics, and desires In this vision, the health care system is seen no lon- as they find expressions, both new and old, in the ger as a drain on the economy, but as an enabler of changing landscape created by Global Health initia- social and economic development. While Farmer’s tives. Their everyday struggles and interpersonal project is by no means accepted as a gold standard dynamics have a way of eluding expert behavioral it has, along with other initiatives of this kind, made modeling and short-lived experimental approaches. significant cracks in the prevailing rationalities The task of the social sciences in the field of Global that guide Global Health interventions and, above Health is to break through these models, experi- all, it has redefined the perceived boundaries of ments, and projections and to produce different feasibility. kinds of evidence as we reckon with historical health disparities and the “pharmaceuticalization” of Conclusion health care. We must also engage crucial questions about the role of the state and the market in Global There are profound discrepancies between how Health design and delivery and investigate what Global Health policies and campaigns are envisaged happens to citizenship when politics is reduced to to work and the concrete ways in which they are actu- survival — all while maintaining a deep and dynamic ally implemented or received by target populations sense of people in local worlds. routinely facing multiple morbidities and economic Engaging with the intricacies of people’s lives — insecurity (Han, 2013). So, how are we to measure their constraints, resources, subjectivities, projects the value of interventions for people, their health, in unfixed social worlds — requires us to constantly and their subjective wellbeing, and how do interven- reset our conceptual compasses and standards tions affect health systems over time? And how can of evidence-making. What would it mean for our people and their advocates resocialize ill health and research methodologies and ways of writing to em- mobilize for a comprehensive right to health? brace this unfinishedness, to seek ways to analyze This essay calls for new and collaborative ways the general, the structural, and the processual while to understand and act on the transnational and local maintaining an acute awareness of the inevitable realities that are emerging in the shadow of large- incompleteness of our own accounts? scale health and development interventions and People know what is troubling them. And it is in an era of ever-expanding global medicine. Amid somewhere in the thickness of social life that criti- broken public institutions and deepening rifts, the cal work always begins. Fieldworkers are uniquely targets of Global Health interventions often implode positioned to see what more categorically minded the units through which they are conceptualized. In experts may overlook: namely, the empirical evi- the meantime, the externalities created by interven- dence that emerges when people express their most tions that come and go are real — leaving multivalent pressing and ordinary concerns which can open up impacts on institutions and social relations that to complex human stories in time and space. The so- have to be addressed on their own terms and that cial realities of “target populations” and the midlevel people escaping grim medical destinies are left to actors on whom the burden of implementation lies reckon with. beg for analytic frameworks that weave intentions
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Recebido em: 12/09/2013 Aprovado em: 15/10/2013
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