When People Come First is an anthology of contributions from leading academics that makes a strong case for a new, integrated approach to global health. Essential to this is the capacity to appreciate the interdependence between “health, development and social justice.” Edited by João Biehl and Adriana Petryna, this collection seeks to critique the long-standing preference among dominant global health actors for vertical interventions which rely on a “triad” of new technologies, individual behavior and scientific knowledge of disease. This de-contextualized focus has resulted in a failure to consider how social and structural factors influence people's choices and options in relation to their health. Through a series of ethnographic case studies that touch upon the complexities of global health as implemented and experienced on the ground, the book's contributors have produced a compelling text supporting their central claim: for a global health strategy to be meaningful, it is time to learn from the daily struggle for survival of those whose health it hopes to improve.
The book is organized over three sections, each filled with four case studies, plus an overview by Biehl and Petryna. The first section, Evidence, consists of critical analyses of the historical development of the institutions and operational ideologies of global health. The second, Interventions, contains empirical, situated accounts of global health interventions. The final section, Markets, focuses on the interaction of emerging health markets (private or third-sector) with state-run healthcare systems and the impact of such networks on global health practice. Taken collectively, the wide-ranging case studies draw the reader into many worlds. What unites the diverse empirical details they present is a common sensitivity to the personal and interpersonal experiences of health and illness, and the role that structural forces play in shaping these experiences. In the process, the contributors illuminate a critical gap that exists between the intentions of evidence-based global health interventions and their outcomes, by showing the reader that disease is complex and, therefore, is “never just one thing” (4).
Each of the 12 individual case studies presented in this anthology is the result of the contributor's long-term involvement in a given field and, consequently, they read as thorough and persuasive. Although each of the case studies is context specific, taken together they span a variety of topics and provide sure evidence that each case is not merely an anecdotal exception, but part of a systemic pattern influencing global health praxis. This serves to strengthen the book's central argument: that the emerging global health of our time must incorporate a people-centred approach which takes account of the unique and often unexpected complexities which influence the outcomes of each health intervention. This argument constitutes a timely critique of the hegemonic status of “evidence-based” practice in global health, which devalues the “counterknowledge” (23) of people within their own contexts in favor of abstract, quantifiable information unsullied by the residues of people's experiences. In response, this anthology puts forward a strident and sound argument that ethnographic research provides an equally valid form of knowledge that must be included rather than diminished by global health policy-makers. Importantly, the contributors do not overreach and seek some kind of preference for the ethnographic method. Instead, they advocate the unique merits of ethnographic insights and conventional scientific knowledge in global health.
Although this anthology makes a strong case for the value of ethnography in global health policy, it is unclear how it could be incorporated into existing systems for delivering this. On this topic, the book is inexplicit. It is, however, an understandable gap. Reconciling the audit culture which dominates many of the large-scale institutions driving global health policy with the messy and often unpredictable reality of local experience is no simple task. Conceiving of a plausible path toward change is hard at this stage, given the entrenched hierarchy of knowledge that positions quantified approaches as objective truth and ethnography as an anecdotal distraction. On a more practical level, ethnography is a time-intensive and costly research method, at odds with the strict emphasis on efficiency governing bureaucratic practice. Consequently, perhaps raising the issues surrounding the sources and terms of knowledge, as this anthology does, is an important first step in recalibrating global health interventions. How these ideas are integrated and operationalized will depend upon continued dialogue that crosses disciplinary boundaries.
When People Come First presents an important contribution to debates surrounding the concept of “evidence” in global health policy and practice, by introducing ethnographic observation, and personal accounts, as a vital form of testimony. The book's case studies are readable and accessible, in the main. Due to its interdisciplinary origins, those working in global health, from high-level policy-makers to on-the-ground staff, would benefit from the insights and perspectives provided by this book. Students and academics interested in global health, human rights, development studies, medical anthropology and associated disciplines will also find the anthology useful. A website, whenpeoplecomefirst.com, accompanies the book, where interested parties can access study guides and read contributor responses for each of the chapters. This anthology, and the debates which it will surely ignite, provides a solid foundation for exploring an approach to global health where people come first.