Review of Vincanne Adams (ed.), Metrics. What Counts in Global Health (Duke University Press, 2016), 258 pages.
Reviewed by Oscar Javier Maldonado Castañeda
Metrics: What Counts in Global Health is a compilation of works edited by Vincanne Adams about the impact of metrics in the shaping of Global Health. The book provides a set of ethnographies about the ways in which numbers and measurement are practiced in Global Health from the estimation of maternal mortality rates in Malawi to the tensions of integrating ethnography to RCT in the Veteran Administration in the U.S. These different stories show how healthcare has been transformed by new forms of governing Global Health based on the actuarial calculation of life as returns to donors’ investments. The authors warn about the consequences of this regimen in which data production overshadows actual healthcare provision. The book offers a strong statement about the importance of ethnography and qualitative accounts of the complexities and contradictions of Global Health.
Keywords Global Health, metrics, quantification, evidence, economisation of life
Global Health is increasingly enacted through numbers. In 2012, the data designer David McCandless presented a 6m x 2m visualisation art-piece called 20th Century Death for the Wellcome Trust exhibition, ‘Death: A Self-Portrait – The Richard Harris Collection’. The piece was a visualisation of twentieth-century mortality rates. Using data from the WHO and the Global Burden of Disease (GBD), the piece skilfully renders visible the main causes of death of humanity. Far beyond war (131 million deaths), the biggest killers have been infectious diseases (1.680 m) followed by cardiovascular diseases (1.246 m.). In the same fashion, the website of the Global Burden of Disease (GBD) curated by the IHME (Institute of Health Metrics Evaluation) offers different visualisation tools of the numbers and data produced by them. Colourful diagrams and maps can be easily produced to compare diseases and countries. McCandless’s motto is that information is beautiful and has been understood by the IHME. The aesthetics of data contributes significantly to its power.
Metrics. What Counts in Global Health offers a thoughtful analysis of the metrics and material infrastructures behind the production of this kind of data, highlighting the ways a data-driven Global Health system has affected the concrete experiences of practitioners, patients and communities. Adams argues that Global Health planners envision a world of diseases constantly in motion — ‘a world in which interventions can be mapped out as problems of scale and measurement rather than a problem of customs, culture, or national political will’ (6). Based on the blurred lines of cause and effect between health and economic development, Global Health organisations have emphasised the importance of measuring impacts and returns of healthcare investment, promising to solve health problems through calculation, evaluation and efficiency.
The book presents a set of ethnographies about new developments in metrics, audit practices and quantification in Global Health and their impact in local care practices and national sovereignity. The book is organised in four sections: Part I: Getting Good Numbers, Part II: Metrics Politics, Part III: Metrics Economics, and Part IV: Storied Metrics — with each section emcompassing two chapters. These sections are accompanied by an introductory chapter and an epilogue written by Vincanne Adams. Each part shows different aspects of doing Global Health through metrics from the contingencies of numbers production, the engagement of data and political governance and sovereignty, to
the tensions and contradictions of the use of metrics to fund programmes and distribute economic resources, and the intersections between metrics and storytelling.
In the introductory chapter, Adams presents the conceptual and empirical background that links the different stories gathered in this volume. According to her, Global Health metrics configure new forms of sovereignty. Whilst post-war international health relies on the cooperation and exchanges between nation-states, ‘Global Health calls for something that will transcend politics altogether’ (23). Metrics appear as the panacea that will finally solve Global Health problems. These metrics are based on the economisation of health, particularly by understanding healthcare as a market. Big Global Health actors such as the Bill and Melinda Gates Foundation have promoted the development of instruments to measure various programmes’ performance and efficiency. For Adams, the most important developments in this new culture of measurement have been the creation of health-adjusted metrics (HALY) to prioritise interventions and the increasing use of RCT (randomised control trials) to evaluate the efficacy of programmes and interventions. In Adams’ view, the problem with these tools is not just the assumptions materialised in equations, but what is done to fill the variables in the first place. Such metrics have contributed to the fiscalisation of life that is part of the increasing participation of actors from economic sectors in Global Health, particularly finance. These actors claim to have found a way of making goods and money through the development and scaling-up of Global Health solutions. Finally, Adams also points out that the most serious consequence of the economisation of health is to think of life as money, where politics is substituted for a market principle. She argues that treating life as a market object is changing our ways of thinking about evidence in relation to health.
“Getting Good Numbers” presents two stories about formulae and the circulation of numbers regarding maternal mortality from technical to public arenas in Malawi (Wendland) and Nigeria (Oni-Orisan). Wendland shows a detailed analysis of the formula to estimate maternal mortality. She notes that a lack of infrastructure to generate the data that metrics demands pushes statisticians to guess the main variables in their estimations, making their models tautological. Numbers act as fetishes in policy arenas and public displays. She argues that indicators become fetishes when the root causes of the problems they are meant to document fade from view and the ways of addressing them are already foreclosed (74): ‘The product of an equation looks like a number and works like a fact, but it is more like the moral of a story’ (78). Oni-Orisan describes the violence that equations and numbers can exert when some experiences and lives are rendered invisible to adjust reality to the demands of metrics. She tells a story about the erasure of maternal deaths in the production of impact data for the program Healthy Mothers Healthy Babies (HMHB) in southwestern Nigeria. The emphasis on getting the right data often obscures the invisiblity that metrics produce. Orisan argues that numbers are enactments of politics in their own right. They are political instruments that can promote or damage careers and professional trajectories. The demand for numerical profiency (and certain kinds of success showing numbers) creates a form of global sovereignity that puts the quality of clinical practices and political processes at risk (99).
“Metrics Politics” discusses the ways metrics are entangled in the local politics of the places in which they are enacted. Marlee Tichenor tells the experience of the Senegalese data retention strike where health workers decided to withhold routine data from patients from the central Ministry of Health without interrupting their duties as healthcare providers. The strike seriously affected funding from many international programmes such as the Global Fund to Fight AIDS, Tuberculosis and Malaria. This event, for Tichenor, shows the priorities of Global Health regimes in which the notions of accountability and citizenship are transformed by the production of health data. Current Global Health governance is based on the concept of performance-based funding and metrics is the legitimate form of evidence. The second ethnography describes how metrics are entangled in conflictive ways with the efforts to assert sovereignty on the Native Yup’ik Alaska (Hales). She shows the tension between local community and federal government in the U.S., describing how an intervention programme based on an approach that attends to the cultural practices of the Yup’ik people struggles to survive when facing the accountability metrics required by the government funding agencies. Practitioners spend time in data collection, often in conflict with their care work.
“Metrics Economics” shows how metrics make possible the economisation of healthcare. Erikson shows a change from accountability to actuarial metrics in Global Health. Drawing on her fieldwork in Sierra Leone and Washington, she documents new forms of financing in which Global Health commodities (drugs, medical devices, water technologies) are conceived as goods to invest money with expectations of profit and ‘objects “lashed up”’ with financial instruments, corporate moneymaking and government policy instruments’ (149). She argues that new Global Health financial instruments are changing our understanding of ‘care’, ‘shifting attention away from people’s suffering to metrics that assume that if money has been made, some sort of care has been delivered’ (161). In the second study, Lily Walkover tells a story about the contradictions in how Global Health practitioners fail in their attempt to adjust their work to the data requirement of funding agencies. She shows the ‘Hesperian Health Guides’’ efforts to reach funding from international bodies that demand quantified reports of impact. The NGO was funded following the spirit of Alma Ata of community empowerment; however, in the current evaluation framework the organisation has had to adapt its work to metrics that cannot account for the particularities of its work with the community. An obsession with numbers is reshaping the kind of work that non-profits do and the kinds of services that are provided to communities (174).
“Storied Metrics” discusses the role of storytelling in resisting and making metrics work. Smith-Morris describes her experience as a qualitative researcher in the clinical trial Spinal Cord Injury-Vocational Integration Programme (SCI-VIP). This project aimed to evaluate the impact of evidence based support employment for veterans with SCI. The trial integrated qualitative methods to describe the universe of representations, experiences and opinion of patients and practitioners in regards to what makes the programme successful. Smith-Morris shows that the study missed insights and practices that emerged from qualitative research because of its emphasis on the fidelity of the study with RCT protocols. As a denouncement, she says ‘the limited room for qualitative data is important and notable’ but simple inclusion of qualitative data in quantitative reports is insufficient since the evaluation regime privileges a poor version of evidence (198). This part closes with a story about Konbit Sante, an organisation that supports Haitian health professionals as a way of improving healthcare services in the country (Minn). The emphasis on relational aspects of healthcare has become a double-edged sword for the organisation, limiting opportunities of expansion but earning an important position amongst the actors of the Haitian healthcare sector. Pierre Minn shows how Konbit Sante strategically produces accounts in the quantified terms that meet the expectations and requirement of Global Health agencies, and in ways that match affective sensibilities of individual donors in the north. Storytelling is thus a key part of a critical engagement with metrics (218).
This volume closes with an epilogue entitled, What Counts in Good Global Health?, wherein Adams highlights how this book provided an ethnographic account of the side effects of metrics and the infrastructures of data production in Global Health. A focus on measurement has become central in Global Health affecting the delivery of care. The stories presented in the book demonstrate how metrics exert violence by numbers but also over the numbers. Metrics in Global Health have rendered marginal and invisible other forms of evidence and effaced experiences that — despite working in practice — cannot be translated into the quantified language of the market.
Adams finishes with what I consider to be the main contribution of this volume: the necessity of a critical engagement with methods and practices to produce evidence in Global Health. The book contributes to the understanding of the political economy of Global Health, tracing the impact of new actors such as financial institutions and big donors in the definition of life and healthcare. It demonstrates the importance of qualitative research in the production of knowledge suitable to the pursuit of good Global Health. Qualitative research has the potential to produce new stories about health that can capture the imagination of the public, catalysing ‘their own therapeutic citizenship’ (200). These stories are urgent; they provide the affective evidence that is excluded from closed numbers.
Nevertheless, I consider the book to be very pessimistic regarding quantification. Although the different contributors express how metrics in Global Health can contribute to the practice of better Global Health, the book does not provide cases which illustrate more positive engagements with numbers. Numbers matter, thus it is important to think with numbers and imagine collaborations in the pursuit of good Global Health. As David Reubi has noted, the economisation of Global Health goes beyond Structural Adjustment (Reubi, 2013). While not disputing the evidence provided by Adams and colleagues of the damaging impact of metrics, cases such as the development of tobacco taxes show that economics and metrics in Global Health are also about market failures and the defence of the public good (Reubi, 2013). The volume tends to present the development of Global Health metrics as a clash between disciplines for the control and definition of good life and health, ignoring the ways in which health economics has intensively discussed the consequences and assumptions of these metrics (Moreira, 2012). An effective critique of the uses and abuses of metrics in Global Health demands creative engagement between the production of numbers and the stories about them.
Oscar Javier Maldonado is a Postdoctoral Research Fellow in the Department of Thematic Studies (TEMA-T) at Linköping University (Sweden) and Associated Researcher of the Group of Social Studies of Science, Technology and Medicine at National University of Colombia (Colombia). His current research is about the analysis of the reception-adaptation of evidence based medicine and health economics in international vaccination policies, particularly in middle-income countries. Oscar completed his Ph.D. in Sociology at Lancaster University in 2015. Email: firstname.lastname@example.org
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