Enter history and you find the missing politics, then and now. When we look at international health interventions historically, it becomes clear that the political and economic requirements of the day and the ideological whims of the elites in charge determine how priorities are set and why they are abandoned. As social scientists unearth the recent history that explains how people become target populations in global health, unexpected anthropological terrains come into view: we find ourselves face-to-face with profound disconnections between how campaigns are designed and the complex ways in which they are actually received and critiqued. The counterknowledge of the people who are actually at the center of things is thus integral to the structures and effects of interventions and has the potential to protect us from the repetition of history.
In his chapter, historian Marcos Cueto explores the politics that shape the world of global health, especially with regard to the treatment of malaria in the 1950s and its iteration in the 2000s in the form of Roll Back Malaria (RBM). The World Health Organization (WHO), the institutional catalyst of international health initiatives, is at the center of Cueto’s account. He vividly describes how the changing interests of the funders and collaborators involved in particular state-market interactions significantly influence how technology and health interventions are imagined and deployed.
In the 1970s, on the heels of the WHO’s failed DDT-centered malaria eradication program, efforts in international health and the magic-bullet model behind them came under heavy critique. During the 1980s and 1990s, however, the United Nations found itself in dire financial straits, unable to collect money from its most powerful member country. As the Reagan and Bush administrations chose to undermine the role of international political arbiters in favor of market forces, the WHO rose as an important institutional channel through which to explore the efficacy of neoliberal approaches to international health and humanitarianism in general. It was in this climate that the WHO was forced to change leadership and to move toward greater integration with the interests and practices of the private sector.
In this history, we see a shift from centrally planned to decentralized interventions and an increasingly heterogeneous field of actors and strategies on the ground vying for funds and access. Within this anarchic environment, burdens of proof and evidence of success are often moving targets. Changes in goals (from eradication to control and back to eradication) lead to similarly circuitous changes in strategies (from spraying to treatment to vaccines; from prevention to treatment and back). As Cueto shows, Roll Back Malaria needed to position itself as a magic bullet in order to retain its position and funding. RBM’s failure to reach its selfimposed goals, the attempts to relegitimize the program through a variety of evaluative practices, and the subsequent issuing of new goals all hint at an institutional landscape of global health in which funding and political clout themselves become the objectives of intervention.
Through Cueto’s historical X-ray of a particular intervention by one of the institutional backbones of global health, we see the machinations and politics that allow institutions to remain relevant and powerful within an ever more contested field of players. This case study also shows how the current configuration of global health, with its emphasis on Public-Private Partnerships (PPPs), arose not simply from firmly held ideological convictions at the WHO, but as a response to a number of external pressures, chief among them a shrinking budget and an antagonistic political arena. The growth of PPPs owes much of its impetus to this mentality, in which the grand scheming of health system building meets the technical and financial know-how of the private sector. We learn how a particular ethics of global health, always looking outside and up toward funders and politicians, began to take hold. Lost in this calculus, as Cueto and the other contributors to this book demonstrate, are the on-the-ground realities and difficulties with which local partners must contend. A micro-level analysis of macro-level politics thus begins the work of providing critical accounts of these processes and of alternatives being imagined.
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Global health institutions, epistemes, and programs have to be traced back to their political, economic, and disciplinary roots. In her critical ethnography, Vincanne Adams studied a resiliency-training program for schoolage children in New Orleans and a safe-motherhood training program for Tibetan health workers. Both programs required health workers to participate in the new and unfamiliar economy of information on which the legitimacy of the programs rested. And in both cases, the demands imposed by the now-predominant evidence-based medicine approach transformed not only the evaluation of the interventions, but also their methodologies, goals, and subjects. The New Orleans program could only be deemed reliable, credible, and, ultimately, fundable, through the acquisition of privately produced and internationally standardized assessment tools. In Tibet, the original project had to be radically altered on statistical grounds: it was not possible to determine whether the intervention was more effective than chance because “not enough women” died. Following the advice of a Maryland research consortium, the program—now upgraded to a “study”—was made “more scientific,” more globally comparable, by abandoning training in safe motherhood and focusing instead on infant mortality for which “better numbers” were available.
In this regime of veridiction and falsification, evidence-based medicine has migrated to the realm of health interventions and has quickly positioned itself as the default language of a growing “NGO industrial complex.” We now see in policy the same logic of the production of experimental subjects and experimental sites that we see in medicine. The confluence of evidencebased medicine (with its standardized approach to clinical research and practice) and the advent of private funding and neoliberal measures of accountability and efficiency have established a set of demands that the traditional players in global health have been ill equipped to handle. Global health data-making has become a profitable business.
As Adams’s study shows, this new landscape of evaluation is displacing the previous goals of interventions, making the purveyance of actual health services secondary to the development of reliable methodologies, the generation of comparable data, and the training of a workforce capable of deploying interventions with similar results at a later date. Abandoned in this move are the experiences of the nominal targets of interventions. The focus is no longer on the sick and their caregivers, nor is much consideration given to the long-standing effects of programs on the lives of people and on public institutions.
Ethnographic accounts of global health projects allow us to demystify claims as to the natural givenness of evidence-based medicine and to determine who constructs them, and how. They provide a window into the workings of new methodological imperatives and their impact on programs, experiments, and practitioners. The voices of people affected by these programs should be recovered, but that is not the end of the matter. Ethnography also brings into view how projects themselves become the object of intervention and gives insight into the ramifying consequences of this shift. This line of inquiry sheds fresh light on the kinds of experts and economies that arise from the modes of governance and values that global health interventions subscribe to.
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Joseph J. Amon’s chapter further explores how knowledge functions, both as a rhetorical device and as a principle orienting global health policy. His focus is on the ways in which certain bodies of knowledge become privileged domains in the fight against HIV/AIDS; how these knowledges are intrinsically entangled in the politics, economics, and morality that underpin efforts to combat the disease; and how they are built on a language of human rights that often obscures effective avenues of care. Amon calls for a people-centered approach to policy decisions, countering other models that would label case-based evidence as anecdotal and that opt instead to allow politics, ideologies, or the market to guide health interventions. Combined with legal analysis, such an approach highlights how the protection and enforcement of some rights in a vacuum, and to the exclusion of others, risks jeopardizing not only individual programs, but also the provision of care in general.
Amon argues that the “right to know,” whatever its form or object (knowing the serostatus of oneself and others, for example, or knowing about HIV/AIDS and its prevention), offers only temporary control over isolated aspects of the disease. Nor is knowledge about prevention and treatment sufficient on its own, for it does not guarantee care or compliance. An emphasis on piecemeal solutions also obscures other aspects of the epidemic, such as its intersection with structural forms of violence, thereby making meaningful and effective interventions even more difficult to establish. Amon thus advocates for a right to know about the barriers that impact one’s care, a right to access to treatment after one’s status has been known, and a right to protections under the law for one’s personal property and against domestic violence and discrimination, as well as a right to confidentiality. These are what he calls “structural rights.”
By bringing the voices of those living and dying with AIDS to bear on the legal and structural analyses of policy, critical studies of global health not only rescue voices left behind by other epistemologies but also offer a way to uncover the inadequacies of current approaches and to orient the development of new ones. Under the right “to be known” that is advocated here, what is so often dismissed as anecdotal becomes instead the nuanced locus of evidence that brings failing systems, simplistic diagnoses, and ineffective treatments into the light of day. Knowledge thus becomes something more than a rarefied technical object produced by programs or states, to be consumed by their populations (HIV positive or otherwise). Rather, it is a relationship between interested actors built on critical thinking that can ground vapid talk of rights, transforming rhetorical gymnastics into sturdy and meaningful understanding and a means to collective well-being.
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The complex ways in which certain discourses become, simultaneously, productive and limiting forces in global health are also at the center of Didier Fassin’s study of the politics of childhood in the context of HIV/ AIDS in South Africa. Fassin employs the concept of “moral economy” to address the ways in which the tragedy of orphanhood became crystallized as a notion; the constellation of moral sentiments within which it has become entangled; the political debates in which orphanhood has been deployed and transformed; and the interventions that have relied on it as an orienting principle.
The construct of children as worthy recipients of protection from disease by society (as victims whose visibility opens new spaces for action) is accomplished through the portrayal of others as negligent and unworthy. This adversarial moral opposition is the result of the history of HIV/AIDS in South Africa, of old prejudices and misconceptions stretched over new social and biological realities. In this context it would seem that children can become valorized victims only if adult men and women are understood to be predatory, lascivious, or weak; the possibility of intervention on behalf of the purified child subject is realized through the erasure of a complex history that entangles men, women, and children, a history that impinges powerfully on the course of the AIDS epidemic. This construct, Fassin argues, is emblematic of the aspirations and contradictions of modern-day humanitarianism.
Here as elsewhere in global health, the vocabulary of emergency hinges on a temporality that insists upon a break from the past. Such an appeal, while effective in marshaling action, serves to mask other factors that may be contributing to the unfolding of the epidemic and to mask as well other actors desperately in need of help. Discourses and interventions couched in the tragedy of AIDS orphanhood thus often disregard South Africa’s violent past and present, and the loss and breakups of families that resulted from apartheid’s political violence and the continuing effects of economic insecurity. In the past as in the present, extended family and close communities often have been called upon when a child loses his or her parents, changing the concept of “orphanhood” at its very roots. Although the emergence of orphans as the face of HIV/AIDS is laudable in that it introduces previously disregarded subjects, it is a concept sustained by many of the same misconceptions that have plagued previous approaches to the disease and that are all too often the products of longstanding racist attitudes.
Fassin positions his case study at the intersection of several historical moments and scales of analysis. This perspective allows us to understand the ways in which certain discourses come into being, circulate, and are transformed over time. We become conscious of both the actors who wield them and the actors who are affected by them, and we begin to understand how these discourses may guide action or inaction. The notion of moral economy provides an important framework through which to analyze the problematization of some people at the expense of others, the network of exchange and symbolic equivalences that turns some into innocent victims worthy of care and others into villains to be disregarded or condemned. The ethnography Fassin offers demands that we recognize public fictions as such and become aware of the power that sustains and perpetuates them. It is this depth of inquiry that makes possible intelligent critique and raises hopes for genuine transformation.