Making global health knowledge: documents, standards, and evidentiary sovereignty in HIV interventions in South India

Abstract

This paper explores how an array of HIV epidemic responders became embroiled in producing quantitative evidence for HIV interventions in India. Based upon extensive ethnographic fieldwork in Karnataka State, I examine the life history of the Gates-funded AIDS initiative in India known as Avahan as a case study to consider the social and political implications of large-scale, standardizing knowledge regimes enacted in the era of global health. Specifically, I analyze a sample of the key material artifacts that are implicated in the production of standardized knowledge in an attempt to illuminate the workings of what I refer to as ‘evidentiary sovereignty’. I argue that documents, forms, and other paperwork used to generate evidence in global health interventions neither merely reflect expert knowledge nor convey information about scientific standards but, rather, are integral to the re-instantiation of sovereignty. The effects of evidentiary sovereignty not only narrow the aperture of global health interventions to overlook the on-the-ground realities that shape health problems, but they also transform the very ground upon which communities responding to HIV epidemics conceive of and enact politics. As highly HIV-affected communities struggle with the bureaucratic demands of intensive form-filling and query agreed upon standards and systems of classification, a form of politicization of knowledge unfurls that pertains to the documents themselves.

Keywords:

• Avahan
• HIV
• India
• documents
• standards
• bureaucracy
• global health
• evidence
• ethnography

Acknowledgements

Particular gratitude is owed to the communities of sex workers, health scientists, and program implementers who generously shared the details of their intervention work. Refinements to this paper were greatly facilitated by the insights of the special editors, Elsa Fan and Elanah Uretsky, the CPH editor, Kirsten Bell, and the anonymous reviewers.