In recent years a head of critical steam has built up around ‘metrics’. This is shorthand for the glut of statistical indicators deployed today in global governance, both by established institutions like the United Nations and its special agencies, and by newer public/private partnerships and non-governmental organisations (NGOs). Their function is to crystallise in a single number a complex area of human behaviour, such as economic productivity, ‘development’ or corruption, then, through the device of comparative ranking, to reveal where a particular country sits on the scale. Thus are norms created, policy decisions shaped, and resource flows determined. The premise of critics is that the progenitors of such indices, be they economists, demographers or epidemiologists, too readily present them as unproblematic and transparent representations of the external world. The task of the softer social scientists, be they historians, anthropologists or sociologists, is to reveal that this is not so. Instead metrics are themselves the products of particular moments and political configurations, whose apparent neutrality cloaks value judgments and the exercise of power.
Thus far global health metrics have not figured much in the literature, so this collection is an important contribution, staking out new ground for debate. Readers of this journal should note that its case studies are not historical. However, its conceptual framework, set out in Vincanne Adams’ editorial chapters and running through much of the rest, is anchored in a particular historical understanding. This blends postcolonial theory, Foucauldian thought and the postmodern Marxism of which Hardt and Negri’s Empire is the characteristic expression. It understands globalisation as the ascendancy of multinational capitalism, in which north–south relations continue to be determined by inequity and under-development. Biopolitics is integral to the ‘rule’ of the ‘global sovereign’, driven not by sympathy or faith in human rights, but by protective and productivist motives. Health metrics, in the form of outcome indicators or the results of randomised controlled trials (RCTs), are a prime instrument through which this agenda is furthered. However, not only are these often based on hopelessly unreliable data, but they also efface the complex realities of health care experienced in local communities. The task of exposing and redeeming this therefore falls to qualitative researchers, and the remaining chapters take up the challenge.
Several authors examine the weakness of data underlying apparently authoritative statistics. Claire Wendland’s impressive contribution builds from the case of an unreported death at a Malawian hospital to interrogate the strategies used in estimating maternal mortality. Margins of error for numbers and trends are so large as to raise severe doubts over population metrics for poor countries without national statistical capacity. Adeola Oni-Orisan makes similar points based on a Nigerian case, arguing that the pressure to supply indicators to unlock resources creates perverse incentives for local politicians to manipulate desired data. The gulf between distant global planners with their call for numbers and the local realities of under-resourced health systems is also illuminated by Marlee Tichenor’s account of a strike by Senegalese health workers, in which the strikers symbolically refused all data retention duties.
Another theme is the imposition placed on small, dynamic NGOs by the obligation to provide outcome data to persuade funders. Molly Hales illustrates this through the health promotion activities of the Yupik (indigenous Alaskans) whose programme raised awareness of colonial subjugation. The distractions and opportunity cost of metrics collation is also demonstrated in Lily Walkover’s case of Hesperian, a United States non-profit organisation providing community health guides. In Pierre Min’s study, the problem for Konbit Sante, whose remit is the support of Haitian medical staff, was that the lag between its training input and system outputs was too long and diffuse for its achievement to be captured statistically.
Other contributions consider health metrics within the political economy of the West. Carolyn Smith-Morris uses research on an employment programme for disabled war veterans to critique the primacy of RCT measures: numbers could show that the intervention worked, but only the accompanying ethnographic study could reveal the messy reality of why it worked. Moving from state to market, Susan Erikson surveys recent efforts to entice big business into global health investment with the promise of mutually beneficial outcomes. Metrics, she warns, are no longer solely tools of accountability but increasingly predictors of profit.
Not all of this fully convinces. The NGO chapters build on the testimony of sector leaders, which may represent special pleading, and no ethnographies were conducted with the funders, who remain faceless wraiths of Empire. Hales’ case is also somewhat undercut when we learn that the subversive Yupik programme did secure continuing funding. Perhaps these examples simply describe an inherent feature of all voluntary sector work? Likewise, Smith-Morris’s account rather disproves her contention, for here an enlightened funder, the Veterans Health Administration, did commission qualitative work precisely to complement quantification; the only real difficulty was that journal publication policies blocked joint reporting. In Erikson’s case too, while suspicions of market intrusion may be justified, there was little hard evidence of deleterious effects, and it remains possible that metrics-driven strategies, like value-based pricing of pharmaceuticals under a strong assessment regime, could eke out societal benefits from private providers.
More generally the historical roots of health metrics in social medicine are not explored. In their own ways, Brian Abel-Smith’s pioneering of comparative health system statistics, or Archie Cochrane’s advocacy of the RCT in health services research, represented social democratic efforts to wrest health policy-making out of the hands of special interests – the medical profession and private providers – by constructing an evidence base that worked for patients and collective funders. However, instead of advocating a recapture of metrics for progressive health politics, Adams suggests a different persuasory rhetoric. The ‘residual stories’ (p. 46) produced by medical anthropologists, she argues, could better motivate action, because they humanise disease, capture complexity and pack a human rights message. This is certainly desirable, but it seems unlikely that politicians administering aid budgets will trade rigorous evaluation for affective narratives anytime soon, particularly given the populist nationalism and xenophobia currently at large in the West. This book brilliantly raises critical consciousness, but in the end readers may remain reluctant quantifiers – for metrics do still provide a galvanising force in global health, ‘however provisional and uncertain they are’ (Wendland, p. 78).
