Book Review

Paul Farmer, MD, PhD

Harvard University
Brigham and Women’s Hospital
Partners In Health

It’s rare that an edited volume achieves any coherence of purpose, much less clarity of style and consistent rigor. The authors and editors of When People Come First, a critical ethnography of the emerging arena known as global health, have done just that, even as they’ve constituted a dramatic, sometimes wrenching, sociology of knowledge. This book brings evidence from some of the most important theaters of global health (Uganda, Mozambique, Botswana, South Africa, India, Chile, Brazil certainly, but also Geneva and New York and Washington) to bear on the debates (legal, economic, political) that structure and are structured by public-health and policy paradigms. They offer this evidence even as these paradigms falter and are re-invented as new state-market formations and novel technologies collide.

Rapid social change is the one constant in this ambitious volume. These pages come to life and are wrenching because they never seek to elide the messiness of experience. As case studies rooted in long familiarity but alive to overwhelming transformation, they will stand the test of time in part because they acknowledge the hopelessness of seeking to capture a static ethnographic present or to serve as illustrations of a readily elaborated “model” of global health practice.  A couple of the more general essays (including Vincanne Adam’s withering critique of the confident claims made for “evidence-based global public health”) are destined to become classic readings in all of the fields now struggling to address one of the greatest dramas of our times: how might we imagine a world with a little or a lot less suffering in it? The more specific reports (impossible for me not to mention Pfeiffer’s account from Mozambique and Livingston’s testimony from a cancer ward in urban Botswana)  resound with the words of the afflicted, their families, and those seeking, sometimes ineffectively for want of the tools of the trade, to palliate suffering.  Thus do both the specific and the general draw on the specifics revealed in a confusing torrent of often contradictory and always complex social facts and fabrications.

Biehl and Petryna have, along with more than a dozen colleagues, offered both solace and vindication. The vindication is for those who’ve long argued that ethnographic evidence is necessary for any sound understanding of the fairly recent, indeed overdue, collision of a crushing burden of disease, emerging audit cultures, and new therapeutic regimes. Since this collision is occurring as the authors write, any undue confidence that it may be understood without attending to (in the editors’ words) “the limitations of expert knowledge-making, and an inexhaustible richness at the core of the people we learn from” is ill-founded. The solace is also for the reader, since this stunning volume reminds us that there is much to be done before any confident claims for the success of global health may be asserted.