Contributors. Vincanne Adams, Susan Erikson, Molly Hales, Pierre Minn, Adeola Oni-Orisan, Carolyn Smith-Morris, Marlee Tichenor, Lily Walkover, Claire L. Wendland
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|Series:||Critical Global Health: Evidence, Efficacy, Ethnography|
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What Counts in Global Health
By Vincanne Adams
Duke University PressCopyright © 2016 Duke University Press
All rights reserved.
Metrics of the Global Sovereign
Numbers and Stories in Global Health VINCANNE ADAMS
The second half of the nineteenth century was a heady time, especially for those who believed that if you had the right metrics, you could rule the world. Nowhere was this more visible than when (as the Economist notes) "those two great imperial rivals, Britain and France, agreed to carve up not merely the world, but the Universe." In 1847 "the British gained control of time, which is why the Earth's prime meridian ... runs through Greenwich, a suburb of London. [Thirty years later], the French annexed length and mass. They kept them, in the form of two lumps of metal, in sealed jars in [the Bureau of Weights and Measures] in Sevres, a suburb of Paris."
The idea of creating universal standards of measurement was arguably more than a practical solution to the needs of maritime trade and currency exchange that calibrated the colonial enterprises of those times. Universal standards required fundamentally new ways of thinking about objectivity itself (as Daston and Galison 2010 have noted). Objectivity, in its own way, served as the invented conceptual counterpart to the hubris of the age of imperialism. It was joined over roughly the same decades by the birth of statistics, the overachieving mathematical offspring of universally standardized time, mass, and weight.
The creation of these systems of counting in relation to standardized notions of measurement enabled a practical set of tools for colonial rule, working to ensure the smooth transition from mercantilism to direct and indirect systems of colonial governance. Historians of science also note that the metrics were a morally aspirational undertaking: they offered the possibility of shared conversations and shared bases for comparison, for evaluation, for stabilizing the truth around complex assemblages of people, life, and nature, and for creating policies for governing that took ethical questions out of the hands of the priests and colonial rulers and put them into the morally neutral hands of scientifically minded experts. Universal metrics offered, in short, new ways of stabilizing the randomness and chaos produced by the violence of colonialism (Scott 1999).
For this reason it is sometimes hard to remember that despite the aspirational opportunities they afforded, universal standards presupposed a unity of purpose and desire for such standards rather than the recognition that, in fact, in order to be "universal" these standards had to be forced upon the world. Their universality, like their objectivity, had to be taught and learned and forged in a crucible of colonial occupations, sometimes against the backdrop of a good deal of resistance and against the hardship of ever new demands on subjective experience (Anderson 2006; Harding 1998; Packard 1989; Rose Hunt 1999; Scott 1999; Vaughan 2001).
Ruptures and Continuities: From Colonial to Postwar International Health Aid to Global Health
The persistence of universal standards into the twentieth century reveals an equal persistence of aspirations that had to be sustained and relearned in the postwar postcolonial era as formerly colonized nations found themselves both liberated and subjugated in new ways. Resurrected over the century that witnessed colonialism's decline, universal standards of measurement and audit were redeployed and reinvented by economists and politicians and formed into architectures of debt and finance that transformed former colonies into recipients of development aid.
Laboring under the universal obligation to adopt a "will to improve" (Murray Li 2007), as "modern believers" (Pigg 1996), or, now, as "trauma portfolio" managers (James 2010), the world's postcolonial poor have over and over again been taught to imagine themselves as needy subjects, as targets of intervention, as hygienic, nutrition-conscious, clinic-seeking, safe-motherhood-striving, and, now, data-producing, entrepreneurial global citizens (Escobar 1994, Ferguson 2006). Never mind that just committing to these identities was not enough then and remains never enough (even when inhabited) for the vast majority of the poorest of the poor to achieve health and well-being; today whole nations have been, by design, kept alive — or at least barely alive and (in the eyes of the cynics) always needing more — in and through these conduits of financial and development aid. Third world debt economies have always relied on the ongoing displacements entailed in the fact that aid seldom eliminates problems of neediness, and the endless effort to configure newer and better ways of intervening to fix the problems of neediness remains ongoing. As a result governments have sometimes been entirely remade to accommodate the protean agendas of donor nations in order to obtain aid, and, in turn, they have participated in new regimes of sovereignty, which, I would argue, still have everything to do with measuring things.
International health development, for its part, has formed one pillar of the postcolonial mosaic at the ever more sensitive sites of bodies, sickness, and death. But if colonial efforts to count things in health imagined no borders, the aftermath of empire witnessed the opposite in the burgeoning form of the nation-state. Even when the worldly aspirations of international health policies were achieved at places like the World Health Organization (WHO), knowing how to implement these policies and how to count their successes and failures was now something that had to be done through national ministries of health, national statistics, and national politics (Chorev 2012; Greene 2008; Rees 2014).
OTHER THINGS REMAINED constant across the colonial-postcolonial divide, including the tangled interdependencies of health and economics. Thus it is clear that while international public health agencies early on offered an antidote to colonialism's rapacious capitalism, they also helped to secure its operations over time. Being globally poor and needy, or healthy, in the six-decade-long era of health development has always entailed and still entails being a conduit for servicing debt and the circulations of capital that this debt allows. These figurations of debt and subjectivity are deeply tied to the use of metrics.
Like the Hindu deity Vishnu, postcolonial health aid might be seen as a being with many arms doing different kinds of things frequently marked by the dual (and competing, even anachronistic) logics of the Washington consensus and its critics — racketing between Friedman's neoliberal policies and Keynesian welfare policies as they are interpreted by health aid organizations. This Vishnu offers two arms to treat malaria and two to sell pesticides; two arms to make motherhood safe and two to sell contraception; two arms to build low-cost latrines and two to convince people to use costly hospitals; two to mix up the oral rehydration solution and another two to sell the essential drugs that would displace these simple remedies.
Not infrequently, it has been the careening back and forth between competing policies that is blamed for the lack of significant progress in international health. The truth is, it is hard to tell which politics (and economics) are actually to blame: Is structural adjustment to blame for having derailed the public health agendas of the 1970s? Or is it structural adjustment's reason for being — ongoing poverty, the poverty that has remained despite twenty years of international health efforts — that was and is to blame, demanding, more aid, more loans and now market solutions (Ferguson 2006)? That is, the displacement of the leftist and liberal-leaning Alma Ata (and the primary health care movement) policies by more conservative policies (the World Bank's growing interest in health, its production of the World Development Report in 1993, structural adjustment and, later, the UN Millennium Development Goals, MDGs) only partly defines the problem we face today, only partially explains the failures.
I would argue that postwar policymakers and their critics have often had in common the fact that no matter which side of the political divide they are on (Keynes vs. Friedman, Sachs vs. Easterly), they seem to agree that economics remains the centerpiece and central solution for all things health backward. One finds, in other words, a persistent reduction of health inequality to problems of economic lack, a focus that returns once again, like the circling vulture above its already dead prey, to problems of politics. Often this politics underpins another, in which the blame for lack of health development progress is shifted onto the nation-state itself, in rhetorics of political will and corruption, which, again, returns us to questions of competing politics over carrots versus sticks in development aid.
Not surprisingly global health arrives as a clarion call for something new and transcendent. Global health calls for something that will transcend politics altogether. What it calls for is better metrics. Metrics, it seems, are the panacea we've all been waiting for. Metrics will, once and for all, get us talking about evidence instead of politics. Metrics today are assumed to be able to give us a value-neutral, but also politically unbiased, way of talking about health problems and their solutions. Nowhere is this more visible than in the latest iteration of grand international health policy called "Global Health 2035: A World Converging within a Generation" (also called the "Grand Convergence" for short; Jamison et al. 2015) where entire health systems are conceptualized as problems that can be solved using the metrics tools of health economics. Thus the trend over time has not been simply away from liberal toward conservative thinking but rather more simply toward the market overall or, as I will show, toward letting the economists do our thinking for us. And how do economists think? Through numbers.
Indeed it seems that today doing global health means caring an awful lot about the numbers. Being able to count what it is we are doing seems to matter more than ever before, and so we participate in ever more sophisticated forms of audit, research, and accounting that are rolled out, chi-squared, and scaled up. The Millennium Development Goals might be hard to reach, but it is not hard to see that the only way to know if we have reached them is if we have good ways of measuring the outcomes of what we are doing now. At stake here, as it was in the nineteenth century, is how to find a metric that can serve as a universal standard.
Measuring Life, Getting to Global Health
In the annual letter from the Bill and Melinda Gates Foundation (2013), Bill Gates opens his report by noting one of the most important problems facing global health programs today:
Over the holidays, I read The Most Powerful Idea in the World, a brilliant chronicle by William Rosen of the many innovations it took to harness steam power. Among the most important were a new way to measure the energy output of engines and a micrometer dubbed the "Lord Chancellor," able to gauge tiny distances.
Such measuring tools ... allowed inventors to see if their incremental design changes led to the improvements — higher-quality parts, better performance, and less coal consumption — needed to build better engines. Innovations in steam power demonstrate a larger lesson: Without feedback from precise measurement ... invention is "doomed to be rare and erratic." With it, invention becomes "commonplace."
Of course, the work of our foundation is a world away from the making of steam engines. But in the past year I have been struck again and again by how important measurement is to improving the human condition. You can achieve amazing progress if you set a clear goal and find a measure that will drive progress toward that goal — in a feedback loop similar to the one Rosen describes. This may seem pretty basic, but it is amazing to me how often it is not done and how hard it is to get right.
If Gates is even close to being right that doing better global health is at least kind of like building a steam engine, then this proposition is, as he says, based on the challenge of building the right kind of instrument for measuring things. His aspiration is both noble and practical, built on the dual desires to rectify problems of health inequality and to use science and technology to do so. But how does one kind of measuring system get chosen over others? That the micrometer was dubbed the "Lord Chancellor" is not to be missed. Just as the Lord Chancellor enabled the steam engine to bring us into the industrial era, we now hope for a new kind of Lord Chancellor that will bring us into a postdevelopment world in which some form of "health for all" will finally be achieved.
Gates is not alone in hoping for a new Lord Chancellor, or what might be called one metric to rule them all. An entire community of emergent global health scholars declares that the commitment to health for all is possible only through ever more complex transformations in the practices of producing and navigating the metrics. Most of the leading textbooks on global health, for instance, focus in their first chapters on measurements and metrics.
A recent installment of the Lancet's coverage of global health, devoted specifically to a conference on global health metrics sponsored by the University of Washington, offers a version of this too. By using better metrics, global health advocates hope that we will set stale political debates to rest and will also get our focus back on what really matters: health. More important, perhaps, we will stop wasting money on interventions that apparently don't work and put more money into those that do, or at least those that promise to work better.
The proliferation of conversations about metrics is tied to other transformations and experiments in how to do health work in the global context and how to pay for it. The "postwar pocket," to borrow a phrase from Jean-Paul Gaudilliere, that grew public multilateral and bilateral institutions committed to state funding for international health development has been shrinking. Indeed if colonial-era health development relied on a mixture of humanitarian, foundation, and missionary efforts working in tandem with colonial and imperialistic government agendas (Brown 1976, 1979; Packard 1997b; Palmer 2010), then the postcolonial development era and its birth of large multilateral institutions for health governance and assistance corralled public resources in unprecedented ways, to some extent limiting the power of the private sector or tethering it to the consensual models of the multilateral public institution.
Today, however, we witness a return to private sector NGO and humanitarian organizations as the institutional forms of choice for doing global health work. Global health today has become a platform that binds the public and private sector interests in novel form, inheriting the common sense of neoliberalism and increasingly mobilizing the private sector and its market-based, profit-driven solutions for all health problems. Old debates over carrots versus sticks have been all but abandoned today for models of aid and development that mix charity and profit, making carrots and sticks part of the same agenda. The public-private alliances emerging in global health that use these tactics, I argue, are now being conceptualized in and through new ways of counting and new languages of metrics. Metrics not only enable us to set aside questions of politics; they also turn moral questions (about these blurrings) into problems of numbers. It is thus no surprise that the Gates Foundation is the one funding both the Institute for Health Metrics and Evaluation (with the University of Washington) and the Health Metrics Network in Geneva (Erikson, this volume). The rise in involvement of private sector corporations and foundations and the subtle ways they tie market interests to health outcomes may make us pause to consider how these might return us to the specter of empire. Still the route to this end point is not direct.
Excerpted from Metrics by Vincanne Adams. Copyright © 2016 Duke University Press. Excerpted by permission of Duke University Press.
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Table of ContentsIntroduction / Vincanne Adams 1
1. Metrics of the Global Sovereign: Numbers and Stories in Global Health / Vincanne Adams 19
Part I. Getting Good Numbers
2. Estimating Death: A Close Reading of Maternal Mortality Metrics in Malawi / Claire L. Wendland 57
3. The Obligation ot Count: The Politics of Monitoring Maternal Mortality in Nigeria / Adeola Oni-Orisan 82
Part II. Metrics Politics
4. The Power of Data: Global Malaria Governance and the Senegalese Data Retention Strike / Marlee Tichenor 105
5. Native Sovereignty by the Numbers: The Metrics of Yup'ik Behavioral Health Programs / Molly Hales 125
Part III. Metrics Economics
6. Metrics and Market Logics of Global Health / Susan Erikson 147
7. When Good Works Count / Lily Walkover 163
Part IV. Storied Metrics
8. When Numbers and Stories Collide: Randomized Controlled Trials and the Search for Ethnographic Fidelity in the Veterans Administration / Carolyn Smith-Morris 181
9. The Tyranny of the Widget: An American Medical Aid Organization's Struggles with Quantification / Pierre Minn 203
Epilogue: What Counts in Good Global Health? / Vincanne Adams 225
What People are Saying About This
"A bracing collection, Metrics reminds us how and why many efforts to measure sickness, injury, and suffering—like some attempts to address them—are often illusory in their alleged precision. Vincanne Adams's withering critique of the confident claims made for 'evidence-based global public health' shows how such cramped understandings miss many other ways of knowing. Drawing on rich case histories from Senegal, Haiti, Malawi, Nigeria, and Alaska, Adams and her colleagues have assembled a portable epistemology that both humbles and inspires. Required reading for anyone interested in global health—and especially for those holding its purse strings."
"A stunning benchmark volume, in measured tones of 'applause and caution,' about the statistical methods that increasingly govern and provide investment opportunities for health interventions, poverty reduction, and much else in the postcolonial world. These new biopolitical economies displace national decision making and often their own humanitarian goals, using tropes of 'suffering individuals' as 'residuals' as symbolic capital to be reinvested and to give numbers affective credibility. But such stories can also expose the fabrications and distortions that the drive for statistical certainty produces, and explain why so many well-intentioned 'evidence-based' interventions fail. Lucidly explaining global health financialization, the volume calls for alternative metrics, complementary methods, and less reliance on abstracted indices and proxies."
“Timely, incisive, and of immense importance, Metrics is the first volume to bring together ethnographic perspectives to critically assess the increasingly outsized role that audit cultures now play in determining the form, content, and politics of global health research and practice. Adding new specificity to the expanding literature on critical studies of global health, Metrics will resonate well beyond the field of anthropology, impacting history, sociology, policy, ethics, epidemiology, and economics."