
































On the Benefits and Limitations of Using Metrics in Global Health 

Review by Lauren Wallace

Metrics: What Counts in Global Health

by Vincanne Adams

Duke University Press, 2016

There has long been a tension between sociocultural anthropology and more quantitative fields such as

demography and medicine (Christman and Maretzki, 1982; Schepher-Hughes 1990; Kertzer and Fricke

1997).  While  some  of  this  history  results  from  differences  in  methodological  and  theoretical

orientations,  it  also  reflects  fundamental  contrasts  in  disciplinary  worldviews.  The  basis  for  the

differences between quantitative and qualitative forms of evidence and methods, and the possibilities

for a productive union between them, have long been discussed by anthropologists.  Metrics: What

Counts in Global Health, a compilation of works edited by Vincanne Adams, builds on this concern by

undertaking a detailed examination of the production and uses of metrics in global health practice. 

One of  the goals  of  this  volume is  to  enable readers  to  think productively about  the benefits  and

limitations  of  metrics.  Adams  defines  metrics  as  “technologies  of  counting,  but  specifically

technologies  of  counting  that  inform global  knowledge”  and  are  “imagined  to  offer  uniform and

standardized conversations about how best to intervene, how best to conceptualize health and disease,

how best to both count and be accountable, and how best to pay for it all” (p.6).  Simply put, global

health  metrics  are  standard,  quantitative  ways  of  measuring  wellbeing  and  the  impact  of  health

interventions. 

Adams  and  the  other  authors  in  the  volume  extend  previous  anthropological  examinations  of  the

problems of quantitative forms of evidence, their contribution to omission and erasure, and their effects



“beyond the numbers” by exploring how metrics are a form of politics in their own right (Schepher-

Hughes 1997;  Bledsoe 2002).  They argue that  the impacts of  metrics,  and the ways that  they are

produced and circulated can be understood in terms of a new kind of “global sovereign”. In the first

chapter of the volume, Adams defines global sovereignty as “a flexible assemblage of data production

that  like  Mbembe’s  fetish,  orchestrates  biopolitical  health  interventions  so  that  they  work  within

capitalism’s terms and limits…” (p.45). Adams and colleagues argue that this type of sovereignty is a

political imperative tied to lingering forms of neoliberal financial arrangements, as well as types of

development aid that both reaffirm and transcend state boundaries. 

The introductory chapter traces the history of metrics from the colonial period through to the post-

colonial focus on the need for development aid. Adams argues that the interdependence of health and

economics, as well as the search for a universal metric, are constants between these time periods. She

provides a detailed account of the development of some of the key metrics in postwar international

health, including the QUALY (Quality Adjusted Life Year) and the DALY (Disability Adjusted Life

Year), which are both ways to quantify the relationship between health and economic value. Next, she

describes the history and uses of the new gold standard in global health metrics – the randomized

control trial (RCT). She concludes with a brief exploration of alternative forms of accounting in global

health, such as stories. She suggests that rather than opening up a space for rethinking evidence, these

narratives often work to reaffirm the legitimacy of quantitative indicators. 

This introductory piece artfully provides the reader with an understanding of the role that history has

played in the rise of metrics, while drawing an outline of some of the broad themes in the forthcoming

chapters. These themes include the difficulty of producing good data,  and the creation of “silos of

exclusion” (p.36), in which data and methods that do not meet the gold standard are rendered invisible.

In addition, Adams explores the “fiscalization” of health, and life, (p.29) both in terms of the ways that

the production of metrics is expensive, and in the ways they are linked to profit generation via public-

private partnerships. 

The volume is divided into four sections: Getting Good Numbers, Metrics Politics, Metrics Economics,

and  Storied Metrics. The first two chapters of the book, both case studies of maternal health in sub-

Saharan Africa, focus on the ways that numbers can place political outcomes over health. Wendland’s

discussion of “wobbly” estimates of maternal mortality in Malawi provides counterevidence for the

idea that statistics are accurate and neutral. In reviewing how maternal mortality metrics are made into



evidence, she shows that although the products of the equations used are assumed to be facts, they hide

uncertainty. Wendland demonstrates how maternal mortality statistics are important politically, and are

treated  as  fetishes  even  though  they  omit  critical  information  and  downplay  the  root  causes  of

problems. Oni-Orison’s account of the Healthy Mothers Healthy Babies Program in Nigeria deepens

the linkage between politics, sovereignty and metrics further by arguing that these numbers are not just

used to advance politics and goals “but they also carry the political clout to determine who will get

reelected to office, who will be promoted to chief medical director of a hospital, and who will win a

government  contract”  (p.85).  Where  numbers  are  conduits  for  securing  local  sovereignty  through

development  aid,  health  programs  become woven  into  politics  and  governance.  Here,  Oni-Orison

illustrates how the politics of record keeping can get in the way of good medical practice, with real

consequences for the treatment of patients. 

Part  II,  Metrics Politics extends the analysis of the interlinkages between metrics,  governance and

sovereignty  by  exploring  how global  health  measurement  becomes  the  foundation  for  regimes  of

governance. In the first chapter, Marlee Tichenor describes the fascinating case of the health workers’

data retention strike in Senegal. Tichenor’s analysis illustrates the way that metrics have outcomes for

citizenship, since a lack of data can undermine the relationship between nations and their status as

participants  in  systems  of  global  health  governance.  While  Tichenor  focuses  on  the  relationship

between data and global citizenship, in her chapter, “Native Sovereignty by the Numbers,” Molly Hales

describes the part that health metrics play in indigenous sovereignty. She shows that the demands for

quantitative data placed on the Healing Our Families program in Alaska has undermined local forms of

treatment and knowledge. 

In Part III,  Metrics Economics, the authors further explore the so-called “fiscalization” of health and

life that Adams introduces in Chapter 1. Drawing on her work in Washington and Sierre Leone, Susan

Erikson’s  discussion  of  market  logics  provides  an  overview  of  the  troubling  links  between

moneymaking  and  global  health  problems.  Erikson  argues  that  more  reflexivity  about  new  fiscal

arrangements in global health is required, since we do not yet fully understand their impacts. In the

second and final chapter in Part III, Lily Walkover provides an overview of the ways donor money

shapes the metrics of accountability at Hesperian Health Guides. She argues that the involvement of

donor support shapes the type of work that non-profits do and in turn makes them complicit in the very

systems they criticize. 



Picking  up  threads  from Hales  and  Walkover’s  discussions,  the  final  chapters  in  Storied  Metrics

examine  more  directly  the  resistance  anthropologists  and  other  qualitatively-trained  individuals

working in global health run up against in working with metrics systems. First, Carolyn Smith- Morris

examines  how ethnographers  work on RCT research with  United States  veterans.  Building on the

theme of omission and erasure introduced in previous chapters, Smith-Morris highlights how clinical

accounts  of “fidelity” fail  to  capture the contextual  data  that  are  important  in veterans’ lives.  She

suggests that social scientists who work alongside RCTs can ensure that more of this contextual data is

reported.  However,  she argues that  the inclusion of  qualitative data  is  insufficient  where decision-

making power rests with clinicians. Next, in his account of Konbit Sante, a medical humanitarian NGO

in northern Haiti, Pierre Minn describes the strategies used by staff to communicate the relevance of

their program to funders. Minn illustrates the way that Konbit Sante’s strategies are a form of resistance

against a limited set of indicators being used to evaluate global health interventions.

Finally,  in  a  very brief  concluding chapter,  Adams explores  future  directions  for  social  scientists’

meaningful engagements with global health metrics. She argues that discussing metrics in ways that

undo their claims is essential. However, she suggests that subscribing to a critically applied medical

anthropology, which also describes new models worth pursuing, is equally important. Adams contends

that  many  anthropologists  and  other  social  scientists  working  in  global  health  have  taken  up  the

challenge  of  including  ethnographic  evidence  in  statistical  and  RCT metrics.  She  provides  a  few

succinct examples of this type of work. For instance, she describes how sufferers of “orphan diseases”

have begun to advocate for the inclusion of small sample sizes in the production of metrics. In closing,

she suggests that while many ways of rethinking the paradigm of global health research have been

proposed, these alternative approaches are still underutilized today. 

The epilogue is successful in assuring readers about the multiple forms of resistance leveled at metrics

by  anthropologists  and  others.  However,  a  few  more  in-depth  descriptions  of  social  scientists’

optimistic  engagements  with  statistical  and RCT metrics  would  be  useful,  particularly  for  applied

anthropologists  and  other  global  health  practitioners.  For  example,  Adams  briefly  mentions  the

groundbreaking model used by Partners in Health, however, she could elaborate more on the ways the

model is particularly useful in thinking about our engagement with metrics.

Overall,  this  volume  is  insightful,  engaging  and  impressive.  Adams  and  colleagues  succeed  in

exploring in detail the limitations of global health metrics and their impacts on what Adams terms



“global health efficacy” (p.6). One of the major contributions of this volume is the way it shows how

the production, circulation, and impacts of metrics can be understood in terms of the “global sovereign”

(p.45). It is clear from the work of Adams and her contributors that as metrics become the organizing

principles for global health, they create new kinds of identities and social relationships that have real

effects  for  health  workers,  nation-states,  and  local,  regional  and  national  governments.  I  highly

recommend  this  enlightening  and  ethnographically  rich  book.  It  is  a  must  read  for  both  medical

anthropologists and global health practitioners, and would make an excellent addition to the reading list

for graduate classes in medical anthropology or global health. 

References Cited

Bledsoe, Caroline. Contingent Lives: Fertility, Time and Aging in West Africa. Chicago: University of

Chicago Press, 2002.

Chrisman, N., and T.W. Maretzki,  eds.  Clinically Applied Anthropology: Anthropologists  in Health

Science Settings. London: D. Reidel: 1982. 

Hahn,  Robert  and  Marcia  Inhorn,  eds.  Anthropology  and  Public  Health:  Bridging  Differences  in

Culture and Society, Second Edition. New York: Oxford University Press, 2009. 

Kertzer, David I., and Thomas E. Fricke, eds. Anthropological Demography: Towards a New Synthesis.

Chicago: University of Chicago Press, 1997.

Schepher-Hughes, Nancy. “Three Propositions for a Critically Applied Medical Anthropology.” Social

Science and Medicine 30, no. 2(1990): 189-97. 

Schepher-Hughes. “Demography Without Numbers.” In Anthropological Demography: Toward a New

Synthesis, edited by David I. Kertzer and Tom E. Fricke, 201-222. Chicago: University of Chicago

Press, 1997.

Lauren Wallace is a PhD Candidate and Vanier Scholar at McMaster University. She is a medical

anthropologist who studies changes in family planning and family formation in northern Ghana.



© 2016 Lauren Wallace


