A pandemic of metrics.

The COVID-19 pandemic prompted critical attention to the performative power of metrics. We suggest that the existential capacities of metrics as a means of pandemic living warrant further consideration. We describe how the COVID-19 pandemic that came into existence as a public health and political event could only have occurred because of the anticipatory metrical practices that were used to transform SARS-COV-2 into a matter of global health concern. By exploring the affective potencies of COVID-19 metrics we show their abilities to engage the public in ways that cannot be contained; in detailing the narrative arcs created through metrics we show their opportunities, misdirections, and erasures. A pandemic way of life persists: a pandemic of metrics.

It Takes More than a Village: Building a Network of Safety in Nepal's Mountain Communities.

Purpose This report from the field details the ways that one small maternal child health NGO, which began its work in Tibet and now works in the mountain communities of Nepal, has established a model for integrated healthcare delivery and support it calls the "network of safety." Description It discusses some of the challenges faced both by the NGO and by the rural mountain communities with whom it partners, as well as with the government of Nepal. Conclusion This report describes and analyzes successful efforts to reduce maternal and infant mortality in a culturally astute, durable, and integrated way, as well as examples of innovation and success experienced by enacting the network of safety model.

Patient-Led Approaches to a Vaginal Birth After Cesarean Delivery Calculator.

OBJECTIVE: To describe patient approaches to navigating their probability of a vaginal birth after cesarean (VBAC) within the context of prediction scores generated from the original Maternal-Fetal Medicine Units' VBAC calculator, which incorporated race and ethnicity as one of six risk factors. METHODS: We invited a diverse group of participants with a history of prior cesarean delivery to participate in interviews and have their prenatal visits recorded. Using an open-ended iterative interview guide, we queried and observed these individuals' mode-of-birth decisions in the context of their VBAC calculator scores. We used a critical and feminist approach to analyze thematic data gleaned from interview and visit transcripts. RESULTS: Among the 31 participants who enrolled, their self-identified racial and ethnic categories included: Asian or South Asian (2); Black (4); Hispanic (12); Indigenous (1); White (8); and mixed-Black, -Hispanic, or -Asian background (4). Predicted VBAC success probabilities ranged from 12% to 95%. Participants completed 64 interviews, and 14 prenatal visits were recorded. We identified four themes that demonstrated a range of patient-led approaches to interpreting the probability generated by the VBAC calculator: 1) rejecting the role of race and ethnicity; 2) reframing failure, finding success; 3) factoring the physical experience of labor; and 4) modifying the probability for VBAC. CONCLUSION: Our findings demonstrate that a numeric probability for VBAC may not be highly valued or important to all patients, especially those who have strong intentions for VBAC. Black and Hispanic participants challenged the VBAC calculator's incorporation of race and ethnicity as a risk factor and resisted the implication it produced, especially that their bodies were less capable of achieving a vaginal birth. Our findings suggest that patient-led approaches to assessing and interpreting VBAC probability may be an untapped resource for achieving a more person-centered, equitable approach to counseling.

Public health works: blood donation in urban China.

Recent shifts in the global health infrastructure warrant consideration of the value and effectiveness of national public health campaigns. These shifts include the globalization of pharmaceutical research, the rise of NGO-funded health interventions, and the rise of biosecurity models of international health. We argue that although these trends have arisen as worthwhile responses to actual health needs, it is important to remember the key role that public health campaigns can play in the promotion of national health, especially in developing nations. Focusing on an example set by China in response to a public health crisis surrounding the national need for a clean and adequate blood supply and the inadvertent spread of HIV by way of blood donation in the early 1990's, we argue that there is an important role for strong national public health programs. We also identify the key factors that enabled China's response to this burgeoning epidemic to be, in the end, largely successful.

Chronic disaster syndrome: Displacement, disaster capitalism, and the eviction of the poor from New Orleans.

Many New Orleans residents who were displaced in 2005 by Hurricanes Katrina and Rita and the subsequent levee failures and floods are still displaced. Living with long-term stress related to loss of family, community, jobs, and social security as well as the continuous struggle for a decent life in unsettled life circumstances, they manifest what we are calling "chronic disaster syndrome." The term refers not only to the physiological and psychological effects generated at the individual level by ongoing social disruption but also to the nexus of socioeconomic and political conditions that produce this situation as a long-term and intractable problem. Chronic disaster syndrome emerges from the convergence of three phenomena that create a nexus of displacement: long-term effects of personal trauma (including near loss of life and loss of family members, homes, jobs, community, financial security, and well-being); the social arrangements that enable the smooth functioning of what Naomi Klein calls "disaster capitalism," in which "disaster" is prolonged as a way of life; and the permanent displacement of the most vulnerable populations from the social landscape as a perceived remedy that actually exacerbates the syndrome.

Re-imagining global health through social medicine.

The conceptual and practical work done by social medicine and global health have often overlapped. In this paper, we argue that new efforts to apprehend 'the social' in social medicine offer important insights to global health along five lines of critical analysis: (1) reconfigurations of the state and new forms of political activism, (2) philanthrocapitalism and the economisation of life, (3) The economy of attention, (4) anthropogenic climate change, and (5) the geopolitics of North and South.

Alternative accounting in maternal and infant global health.

Efforts to augment accountability through the use of metrics, and especially randomised controlled trial or other statistical methods place an increased burden on small nongovernmental organisations (NGOs) doing global health. In this paper, we explore how one small NGO works to generate forms of accountability and evidence that may not conform to new metrics trends but nevertheless deserve attention and scrutiny for being effective, practical and reliable in the area of maternal and infant health. Through an analysis of one NGO and, in particular, its organisational and ethical principles for creating a network of safety for maternal and child health, we argue that alternative forms of (ac)counting like these might provide useful evidence of another kind of successful global health work.

Saving Tibet? An inquiry into modernity, lies, truths, and beliefs.

Social theorists have explored the ways in which quantification serves as an instrument of governance in the modern state, whether tied to concerns of population size and quality or to problems of social behavior. Biopolitics are as visible in the modern socialist states as they are in free-market democratic states, and they are perhaps nowhere more visible today than in the new global standards of "evidence-based medicine," wherein it is assumed that only quantifiable evidence can serve to establish policy, procedure, and outcome. When it comes to creating ways to "civilize" and organize their target citizenry through health development, Socialist China as relied on such technologies as much as have health development funding agencies from donor countries. In this article, I look at quantitative methods in relation to assumptions that morality can be severed from truth and that numbers are potentially morally neutral. This idea is tied not only to forms of modern subjectivity but also to the distinct ways in which certain linguistic and theoretical practices relate to provisional notions of "lying," "truth-telling," and ways of "believing." An exploration of the effects of attempts to quantify maternal behavior, morbidity, and morality in rural Tibet highlights the problem of morality within an environment in which numbers are never free-standing but, rather, are always presumed to carry moral messages, and in which domains that cannot be quantified serve as a primary basis for knowing truth. Through an exploration of rural Tibetan encounters with health development programs for safe motherhood, I provide a critique of quantification and return to questions about "belief" as a rubric that interrupts modern dichotomies of lies versus truths.

The challenge of cross-cultural clinical trials research: case report from the Tibetan Autonomous Region, People's Republic of China.

Efforts to conduct Western clinical research in non-Western medical settings with little or no familiarity with such methodologies are on the rise, but documented accounts of the ways that biomedical science requires negotiation and translation across cultures are not plentiful. This article adds to this literature through analysis of an NICHD-funded collaborative research effort in women's health carried out in the Tibetan Autonomous Region of the People's Republic of China. The research involved a feasibility study for an eventual clinical trial comparing Tibetan medicine with misoprostol for preventing postpartum hemorrhage in delivering women. It explores strategies of negotiation and translation in and around notions of the scientific method, informed consent procedures, randomization, blinding, placebo, and concepts of medical standardization.

"There is such a thing as too many daughters, but not too many sons": A qualitative study of son preference and fetal sex selection among Indian immigrants in the United States.

In response to concerns from feminists, demographers, bioethicists, journalists, and health care professionals, the Indian government passed legislation in 1994 and 2003 prohibiting the use of sex selection technology and sex-selective abortion. In contrast, South Asian families immigrating to the United States find themselves in an environment where reproductive choice is protected by law and technologies enabling sex selection are readily available. Yet there has been little research exploring immigrant Indian women's narratives about the pressure they face to have sons, the process of deciding to utilize sex selection technologies, and the physical and emotional health implications of both son preference and sex selection. We undertook semi-structured, in-depth interviews with 65 immigrant Indian women in the United States who had pursued fetal sex selection on the East and West coasts of the United States between September 2004 and December 2009. Women spoke of son preference and sex selection as separate though intimately related phenomena, and the major themes that arose during interviews included the sociocultural roots of son preference; women's early socialization around the importance of sons; the different forms of pressure to have sons that women experienced from female in-laws and husbands; the spectrum of verbal and physical abuse that women faced when they did not have male children and/or when they found out they were carrying a female fetus; and the ambivalence with which women regarded their own experience of reproductive "choice." We found that 40% of the women interviewed had terminated prior pregnancies with female fetuses and that 89% of women carrying female fetuses in their current pregnancy pursued an abortion. These narratives highlight the interaction between medical technology and the perpetuation of this specific form of violence against women in an immigrant context where women are both the assumed beneficiaries of reproductive choice while remaining highly vulnerable to family violence and reproductive coercion.

Aging disaster: mortality, vulnerability, and long-term recovery among Katrina survivors.

Data from this multiyear qualitative study of the effects of Hurricane Katrina and flooding in New Orleans suggest differences in how the elderly cope with disaster. At the time of the disaster, the elderly of New Orleans were at greater risk than other groups, and more elderly died than any other group during the storm and in the first year after. Those who did survive beyond the first year report coping with the long-term disaster aftermath better than the generation below them, experiencing heightened stresses, and feeling as if they are "aging" faster than they should. We offer insight on how we might define and characterize disasters, and illustrate that long-term catastrophes "age" in specific ways.

Global health diplomacy.

A variety of shifts emergent with globalization, which are reflected in part by nascent programs in "Global Public Health," "Global Health Sciences," and "Global Health," are redefining international public health. We explore three of these shifts as a critical discourse and intervention in global health diplomacy: the expansion in non-governmental organization participation in international health programs, the globalization of science and pharmaceutical research, and the use of militarized languages of biosecurity to recast public health programs. Using contemporary anthropological and international health literature, we offer a critical yet hopeful exploration of the implications of these shifts for critical inquiry, health, and the health professions.

Informed Consent in cross-cultural perspective: clinical research in the Tibetan Autonomous Region, PRC.

Procedures of Informed Consent are considered a high priority for international biomedical research. However, informed consent protocols are not necessarily transferable across cultural, national or ethnic groups. Recent debates identify the need for balancing ethical universals with practical and local conditions and paying attention to questions of cultural competence when it comes to the Informed Consent process for clinical biomedical research. This article reports on the results of a two-year effort to establish a culturally appropriate Informed Consent process for biomedical research in the Tibet Autonomous Region in the People's Republic of China. A team of Tibetan and American researchers, physicians, health professionals and medical anthropologists conducted the research. The Informed Consent was specifically for undertaking a triple-blind, double placebo-controlled randomized clinical trial of a Tibetan medicine compared with Misoprostol for reducing postpartum blood loss. The findings suggest greater need for flexibility and cooperation in establishing Informed Consent protocols across cultures and nations.

Having a "safe delivery": conflicting views from Tibet.

In the Tibetan Autonomous Region (TAR) of the People's Republic of China (PRC) maternal mortality ratios remain among the highest in the world. Although traditional Tibetan medical theory, practice, and pharmacology include information on maternal and child health care, Tibet is one of the few societies in the world that does not have traditional birth attendants or midwives. Using ethnographic methods, we gathered data from individual interviews with rural Tibetan women (N=38) about their beliefs and behaviors surrounding pregnancy and childbirth. Additional data were gathered through interviews with prefecture, county, and township health care providers. These data were used to develop a culturally appropriate village birth attendant training program in rural Tibet. We describe Tibetan women's perspectives of "having a safe delivery" in relation to concepts about "safe delivery" according to evidence-based medicine in the West. Our work also provides an example of the benefits and challenges that arise when ethnographic research methods are used to design and implement health care interventions.