- When People Come First: Critical Studies in Global Health ed. by João Biehl and Adriana Petryna
These are boom times for global health. Displacing earlier formulations such as tropical medicine and international health, the new moniker now authorizes a range of projects and adorns multiple programs, particularly in the United States. As the editors of this timely volume note, the change is not merely semantic, but [End Page 848] rather reflects a major shift of priorities, resources, and goals. Instead of fostering the growth of national health services in given countries, the global approach emphasizes interconnections between populations, along with increased audit, public-private partnerships, and vertical programs targeting specific problems. A fertile mix of shifting state policies and growing corporate interests—along with humanitarian sentiment and the earnest energy of a legion of researchers and students—have combined to create a veritable new industry. Its initiatives continue to expand worldwide, seeking to measure, educate, vaccinate, test, and treat an array of human targets.
When People Come First suggests that the results of all this global activity are not simply salutary. The book is at once a work of careful scholarship and an unabashed appeal for critical reflection derived from ethnographic and historical inquiry. The product of a workshop held at Princeton University in 2010, it offers a set of case studies written by anthropologists and like-minded scholars. As reflected in the title and explained in the introduction, the collective goal is to counterbalance the bureaucratic abstraction of public policy with “peopled accounts”—narratives that emphasize human needs and perspectives, and thus the local realities of this mode of health care.
The text divides into three sections of four chapters each, addressing respective themes of evidence, interventions, and markets. The first set of essays situates contemporary trends, in particular increasing emphases on technical solutions, data, law, and moral sentiment. Marcos Cueto traces the reemergence of technical emphasis in malaria control, suggesting a strong resonance between the present moment and 1950s triumphalism. Vincanne Adams examines the expansion of evidence-based medicine and clinical trials onto the global scene, underscoring the human blindness that can accompany statistical insight. Joseph Amon reveals tensions between the collective “right to know” HIV status and the legacy of human rights campaigns related to AIDS activism. Didier Fassin’s contribution explores the moral economy surrounding childhood and analyzes how children emerged as a “consensual object of concern” (p. 128) within public health, exemplified by prevention of mother-to-child transmission, sexual abuse, and orphans.
The second part of the book showcases close studies of specific interventions. Tellingly, all come from sub-Saharan Africa, the center gravity of the global health constellation, and two feature HIV/AIDS, its most defining disease. Susan Reynolds Whyte, Michael Whyte, Lotte Meinert, and Jenipher Twebaze map AIDS care in Uganda, focusing particularly on forms of “clientship” related to treatment received from a complex of separate projects rather than a single coordinated source. James Pfeiffer explores related themes in Mozambique, looking at the effects of the major U.S. AIDS initiative (PEPFAR) on that country’s health system. Taken together, the two chapters emphasize a continuing need for administration and basic services, too often sacrificed amid technical innovation. In her contribution, Julie Livingston surveys the looming epidemic of African cancer from the perspective of Botswana’s lone cancer ward. Here ethnography reveals the suffering of underpalliated patients in excruciating detail, clarifying the stakes of both pain recognition and the inadequacy of drug supplies. Amy Moran-Thomas then adds a literal twist to the [End Page 849] worm’s-eye view by examining Guinea worm eradication in Ghana, where the very success of the Carter Center’s campaign against a spectacular parasite highlights the ultimate limits of any vertical, disease-specific approach.
The last section of When People Come First turns to economic considerations, and the complex interplay of markets in global health. Stefan Ecks and Ian Harper demonstrate how tuberculosis treatment in India involves a...