‘When People Come First: Critical Studies in Global Health’ João Biehl & Adriana Petryna (Eds.) (Princeton University Press, 2013).
Global health is concerned with health in a globalised world, characterised by ‘spectacular medical advances and amazing economic growth [… as well as] wide disparities in health and well-being’ (Benatar & Brock 2011:14). The global health architecture, in comparison to international health or public health, consists of a multiplicity of actors ‘all vying for resources and influence in the political field of global health, each seeking to remain a relevant and powerful player’ (p. 6). This awareness of health and disease that transcends all borders is primarily driven by scientifically based schemes of evaluation, particularly evidence-based medicine and random controlled trials, as well as economic calculations to determine cost-effectiveness. These bodies of knowledge have become ‘privileged domains’ in the present health discourse and determines the agenda and priorities of health interventions without asking ‘what the most important health-related information is, who collects it, for what (or whose) purposes, and to what ends’ (Benatar & Brock 2011:15; p. 26 and Chapter 2 of this volume).
With the collection of essays in When People Come First, the authors change the lens of analysis in global health discourse and champion the role of ethnography – a core anthropological methodology – in laying bare the stories of the individuals and communities on whose lives the abstract and bureaucratic considerations of public policy impact. They argue that global health ‘overemphasise individual risk factors that ignore how health risks are shaped by law, politics, and practices ranging from industrial and agricultural polities, to discrimination, violence, and [a] lack of access to justice’ (p. 3) An integrated approach, that ‘recognize[s] the profound interdependence of health, economic development, good governance, and human rights’, is therefore essential for a ‘critical global health perspective’ (p. 4).
The twelve essays in this volume are organised under three headings – Evidence, Interventions, and Markets – and each category is preceded with an introduction and overview by the editors, JoãoBiehl and Adriana Petryna. The authors are as diverse as the stories they tell and anthropologists (Vincanne Adams; JoãoBiehl; Stefan Ecks; Dider Fassin; Michael M.J. Fischer; Clara Han; Ian Harper; Lotte Meinert; Amy Moran-Thomas; Adriana Petryna; James Pfeiffer; Jenipher Twebaze; Ian Whitmarsh; Michael A Whyte and Susan Reynolds Whyte), historians (Marcos Cueto and Julie Livingston), and an epidemiologist and human rights scholar (Joseph J. Amon) offer empirical and theoretical perspectives on global health-related initiatives and epistemologies, and particularly on the actual impact of these initiatives on care, health systems, and governance (p. 4). The essays are based on field notes, interviews, life histories, and database and document analysis, each showing how the global health machinery becomes entangled in local public health landscapes and its legal, political, social and medical realities.
All the essays offer food for thought and make a valuable contribution to the objectives of this publication. The essay by Susan Reynolds Whyte and her colleagues (Michael Whyte; Lotte Meinert and Jenipher Twebaze) place people first by considering their role as clients or consumers of healthcare (Chapter 5 of the volume). Whyte et al discuss the notion of ‘therapeutic clientship’ in the managed care marketplace where patients are seen as clients or consumers of health products, and the fiduciary doctor-patient relationship is reduced to a contractual agreement. They argue that the agency of patients is recognised when they are viewed as clients or consumers and that this ‘provides a point of entry to assess the micropolitics in which health and health care are brokered’ (p. 134). However, while the notion of clientship in healthcare empowers patients and gives due recognition to their autonomy and agency, the authors fail to address how such a view also leads to the commodification of health and healthcare services and what this commodification of a health mean for patient rights and the obligation of states to provide for their citizens’ health.
The authors of this essay claim for example, that ‘the term “client” implies a more enduring relationship, unlike an exchange with a customer or even a patient, which might be a one-off affair’ (p. 150). This, however, is in stark contrast to the prevailing opinion in health law that a contractual doctor-client relationship, that is based on notions of consumerism and clientship (as opposed to the traditional fiduciary doctor-patient relationship), discounts the social dimension of medical care and the clinical realities of medical practice and will ultimately lead to the commodification of health as a mere ‘service’ to be bought and sold on the marketplace (see Teff 1994:116; Le Roux-Kemp 2011; Pellegrino 1999:252). How these contradictions play out in the context of the Ugandan health system would have offered a valuable insight into the increasing commercialisation of health as a social good. (Health is generally regarded not as a commercial or market product, but as a social good; a vital capability of human life warranting access to health care for every person, community and society.)
Another important theme in global health studies that also features in the essays of this publication is the indeterminability of human rights discourse in general, and of the ‘right to health’ in particular. Joseph Amon’s essay on the seemingly contesting rights in the HIV/AIDS milieu is especially telling of human rights discourse, as ‘expressions of a normative moral imperative’ (O’Cinneide 2011; Chapter 3 of this volume). Amon discusses the right to know one’s HIV status in relation to a range of other related rights, including: the right to know the HIV status of others; the right not to know and live in uncertainty; the rights to access to information relating to HIV/AIDS; freedom and security of one’s body and person; medical confidentiality; access to medicines and healthcare; and the criminalisation of HIV transmission. Amon highlights how human-rights talk can obscure effective avenues of care and rightly questions the absence of the right to human dignity in the rights discourse of health and well-being.
For me, however, the most compelling of all the essays is by Julia Livingston on the emerging epidemic of cancer in Botswana (Chapter 7). Her essay, which is based on the lived experience of pain in a context of scarcity (an oncology ward in a public health facility in Botswana), shocks the reader back to the harsh reality where ordinary people, devoid of the most important and vital quality of life – their health – continue to laugh and cry, endure and survive. So vivid are her reflections that the reader can almost smell the blood of the amputation, feel the botlhoko [pain] of the bone marrow biopsy, and laugh at the hopelessness of our own impermanence.
The aim of the authors’ in When People Come First is explicit: They call for a holistic, people-centered approach that involve and inform the multiple stakeholders of global health ‘to create a health sufficient to liberate human potentials and futures’ (p. 5). This they do by offering ethnographic case studies as an alternative heuristic framework for global health; an approach akin to the multidisciplinarity of medical humanities and recognizing the social and cultural context of healthcare and disease. Many may question, however, whether this publication truly succeeds in setting a new agenda for research in global health; because how a multidisciplinary collaboration of knowledge-making in global health should be achieved, still remains unclear. In fact, the authors are themselves unable to completely transcend their own disciplinary boundaries in achieving this goal.
Yet, this ‘inevitably awkward relationship’ that exists between the ‘unique character of ethnographic praxis’ and the ‘historical phenomenon of global health’, is central in this publication When People Come First, and is used to remind us of the intended and unintended ‘local realities’ of global health, a discipline that is still debating the boundaries of its own existence (Pigg 2013:127).
Reviewed by Dr Andra le Roux-Kemp, who works on the interstices that exist between the law and other disciplines, specifically the medical sciences, medical anthropology and bioethics. She has recently been appointed as Assistant Professor at the City University of Hong Kong, and is a part-time lecturer at the Faculty of Law, Stellenbosch University (South Africa) and an ema2sa scholar at the Institute of Social and Cultural Anthropology, Freie Universiät Berlin (Germany). She holds the degrees BA LLB (Stell), CML (UNISA), LLD (Stell), BMus and Hons BMus (UNISA). Her current research project explores the moral economies of Universal Health Coverage in South Africa and Ghana.
Correspondence to Andra le Roux-Kemp.
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O’Cinneide, C. 18 March 2011. ‘Emerging models of socio-economic rights adjudication: Lessons from home and abroad’. Unpublished workshop paper presented at the Advancing Economic and Social Rights: Current Issues in Research workshop held at Palace Green Durham University.
Pellegrino, Edmund D. 1999. ‘The commodification of Medical and Health care: The moral consequences of a paradigm shift from a professional to a market ethic’. Journal of Medicine and Philosophy. Vol. 24, No. 3, 243-266.
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Teff, Harvey. 1994. Reasonable Care: Legal perspectives on the doctor-patient relationship. Oxford: Claredon Press.