Book Review: When People Come First is a Reality Check for Global Health

Jocalyn Clark reviews a new anthology of case studies in global health by leading scholars in anthropology, history, and human rights that provide richness and depth often missing in traditional journal articles

When People Come First. A compelling notion for anyone interested in health and development. And a compelling title for an anthology of case reports offering “critical studies in global health.” As the field of global health is growing in size and profile, critical analyses are missing, say João Biehl and Adriana Petryna, the editors of this book.

The book starts from the premise, implicitly, that people do not always come first in global health research and policy.  As such, the editors have gathered the work of interdisciplinary scholars focused on individual accounts of health, arguing that the current fashioning of global health focused on narrow “magic bullet” health interventions must be transformed to produce a more holistic view that is oriented toward providing value to patients rather than simply access to discrete therapeutic interventions like drugs, devices, and services. The holistic view is composed of local realities and local contexts, for example, the “ups and downs” of how individuals and communities grapple with inequality, with accessing health care and technology, and with fighting for the right to health. The editors argue this type of in-depth work allows for an examination of the societal, political, and economic factors that contribute to people’s health and outcomes, and that the most effective solutions in global health are to be found in people themselves.  As the editors say, “the global health community has overemphasized individual risk factors that ignore how health risks are shaped by law, politics, and practices ranging from industrial and agricultural policies to discrimination, violence, and lack of access to justice.”

The book is a series of case studies involving governmental and nongovernmental agencies, public-private partnerships, and health care settings and communities around the developing and developed world – including Botswana, Brazil, Chile, India, Uganda, and the US. The material is organized around three themes of evidence, interventions, and markets. Collectively the cases tackle key problems in global health including the limits of technological solutions, the translation of evidence-based medicine into global health policy, the politics and access to global health knowledge, HIV treatment, and the neglect of non-communicable disease, including mental health, in the global health field. The markets section delves into the rise of the private sector in global health and humanitarianism, including the proliferation of private-private partnerships and philanthropic organizations, and what this means for the traditional role of the state in providing health care and humanitarian relief, as well as sustainable development.

It draws heavily on anthropological techniques for generating “peopled accounts,” described by the editors as “stories that are so often hidden from view, obscured by more abstract and bureaucratic considerations of public policy.” In promoting the view of individuals and lived experience as central, the anthology highlights the role of ethnography as an empirical tool for applying a more comprehensive, people-centred approach. Ethnography generates fieldnotes, interviews, life histories, and database and document analyses, and the resulting written cases are built by a combination and integration of empirical data and theoretical analyses.

In some instances the accounts described in the book are unsettling – in the sense that they jar one’s traditional ideas of global health problems and interventions. Consider the story of Violeta, an anchor of Clara Han’s case explicating the role of labour instability, antidepressant abuse, and violence in a northern Chilean community’s mental health and suffering. Violeta is a single mother to her dead brother’s daughter, living together but in conflict with her parents about her efforts to contribute financially to the household. Able only to secure unstable part-time piece work and struggling with disabling health problems, Violeta’s parents rely more and more upon their daughter to help secure the family’s basic needs, contributing to Violeta’s worsening mental health and dependence on antidepressant and pain medications, which she hoards from her group therapy sessions. These treatments had been introduced in the primary care setting in her community as part of modern treatment for depression.  It’s impossible in a few sentences to do justice to the richness and detail of the case study, but suffice to say it effectively skewers the medicalized response to global mental health issues found in the “packages of care” promoted in The Lancet and PLOS Medicine, revealing them to be oversimplified and bare. Trained in both medicine and anthropology, Han knows that “the effectiveness of the package hinges upon community conditions that allow psychosocial interventions to gain traction and to work their way into everyday lifeworlds.”

Han reflects the approach of all the collection’s case studies when she states that while epidemiology accounts for “common mental disorders – such as depression and generalized anxiety disorder – by charting the prevalence of symptoms that count toward such disease categories within a given population…., ethnography, on the other hand, helps us attend to the unpredictable, singular, and discontinuous experience of unstable and changing work regimes and their relationship to the manifestation of depressive symptoms.” The more holistic, historical view makes clear how health is locally experienced and what the costs of health really are in everyday life, which Han argues can help to approach “care” differently. That the anthropological account stands in such tension with the medicalized one makes for fascinating and illuminating reading.

In fact, all the case studies – whether focused on HIV, malaria, noncommunicable diseases, or randomized controlled trials – offer critical, seemingly fresh analyses from interdisciplinary perspectives that are true “eye-openers” for global health traditionalists.

At times the language of the anthology can be opaque for a general reader unfamiliar with “reductionist epistemic frameworks” and “denaturalizing operational categories,” but fortunately these forays into social theory-speak are limited and the volume, focused as it is on detailed narrative, is remarkably readable.

Case studies of this depth, length, and conceptual rigour are unlikely to find their way into medical journals – this is a shame, as the insights the “global health humanities” offer is revealing. When People Come First would be a valuable accessory in any global health practitioner’s toolkit, and essential reading for global health students.

When People Come First: Critical Studies in Global Health, ed. by João Biehl and Adriana Petryna is published by Princeton University Press, ISBN: 978-0-691-15739-9

Jocalyn Clark (@jocalynclark), a former Senior Editor at PLOS Medicine and former Assistant Editor at BMJ, is a 2013 Rockefeller Foundation Bellagio Resident working on her writing project “the medicalization of global health.” She declares no other competing interests.

Books reviewed in Speaking of Medicine are independent of the book’s publisher. Reviewers do not receive a fee but are allowed to keep the review copy of the book.