Medical Anthropology

Cross-Cultural Studies in Health and Illness

ISSN: 0145-9740 (Print) 1545-5882 (Online) Journal homepage: https://www.tandfonline.com/loi/gmea20

Anthropologists in Global Health Experiments

Anita Hardon & Robert Pool

To cite this article: Anita Hardon & Robert Pool (2016) Anthropologists in Global Health
Experiments, Medical Anthropology, 35:5, 447-451, DOI: 10.1080/01459740.2016.1177046

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MEDICAL ANTHROPOLOGY
2016, VOL. 35, NO. 5, 447–451
http://dx.doi.org/10.1080/01459740.2016.1177046

COMMENTARY

Anthropologists in Global Health Experiments

Anita Hardon and Robert Pool
Department of Anthropology, University of Amsterdam, Netherlands

ABSTRACT KEYWORDS
Can global health experiments be part of more flexible systems of knowl- Evidence based medicine;
edge generation, where different bodies of knowledge come together to ethnography; global health;
provide understanding not only of the outcomes of new interventions experiments
but also of the mechanisms through which they affect people’s well-
being and health? Building past work in which they tried to transform
how global health experiments are carried out and inspired by the
articles in this special issue, the authors of this commentary argue that
strategic collaboration is needed to break the hegemony of randomized
controlled trials in designing global health technologies. More open-
ended experiments are possible if anthropologists team up with innova-
tive researchers in biomedicine to develop new conceptual models and
to adopt novel observational techniques and ‘smart’ trials that incorpo-
rate ethnography to unravel complex interactions between local biolo-
gies, attributes of health systems, social infrastructures, and users’
everyday lives.

Evidence-based medicine reigns supreme in Global Health. The articles in this issue focus on the
ambivalences and tensions of translating evidence into care, or producing evidence while delivering
care, and the problematic nature of evidence-based medicine in the ‘real’ world.
Randomized controlled trials are the gold standard to evaluate and generalize the efficacy of
interventions across diverse sociocultural contexts. Outcomes of these trials are considered valid if
they have been measured with sufficient statistical power (a large enough n) against a comparative
case, and if results are shown to be reproducible (Adams 2013). Social scientists have criticized these
trials for ignoring the social and infrastructural conditions that impinge on how technologies work,
and for their optimistic belief in generalizability (Adams 2013; Geissler 2013; Epstein 2004). What if
contexts actually determine which interventions work? Or, in line with what the guest editors of this
volume suggest, what if contexts interact with technologies and with people administering and using
them, thus upending easy hopes that we can simply scale up and generalize results validated under
specific, local, and contingent conditions?
Over the past two decades, researchers at the University of Amsterdam have been part of
numerous endeavors to transform how global health experiments are carried out. We have con-
ducted preliminary studies to help design interventions and have proposed mixed methods to
examine how technologies are used (Hardon 2010; Pool et al. 2010; Stronks, Wieringa, and
Hardon 2013). We have tried to replace the testing-machine model (Rheinberger 1993) of global
health research with a more flexible and iterative approach that incorporates new biosocial under-
standings that emerge during the experiments. The problem with clinical trials has less to do with
inherent limitations in their design, but the unimaginative and rigid ways in which they are used to
generate evidence. We have tried to convince our colleagues that by pursuing ethnography within
experiments, we can contribute valuable insights on how and why interventions have beneficial

CONTACT Anita Hardon a.p.hardon@uva.nl Department of Anthropology, Center for Social Science and Global Health,
University of Amsterdam, PO Box 15508, 1001 NA Amsterdam.
© 2016 Taylor & Francis
448 A. HARDON AND R. POOL

outcomes and how they interact with the environments in which they are used. This requires moving
beyond locating efficacy solely in active substances or technological innovations that are the focus of
experiments. We call for new conceptual frameworks that acknowledge how efficacy is mediated by
contexts and influenced by expectations and user practices. As Geissler (2013) suggested, global
health researchers are well aware of these complexities, but tend to simplify matters in order to make
trials feasible.
Although clinical researchers appear increasingly willing to engage with anthropologists in
clinical trials, many funding bodies remain wary of mixed methods experiments. More than a
decade ago, this led us to engage more explicitly in debates over the design and epistemology of
randomized controlled trials. The Dutch Foundation for Health Research commissioned us to
propose methodological innovations to better account for how diversity influences the outcomes
of medical interventions. To answer this challenge, we brought together people from a wide variety
of backgrounds including clinical epidemiologists, pharmacologists, statisticians, and social scien-
tists, to generate a set of recommendations. In our report, we noted that socioeconomic, biological,
and cultural/behavioral differences between patients have received insufficient attention in clinical
trials mainly because of a lack of conceptual clarity, a lack of agenda setting, and a lack of any
methodological gold standard on how to address these inter-related bio-social factors (Wieringa et al.
2005; Stronks et al. 2013). We proposed a broad definition of diversity including biological, genetic,
sociocultural, dietary, psychological, and economic factors that interact to generate the efficacy of
treatments. The expert meeting at which our findings were discussed called for a paradigm shift in
clinical research to go beyond the use of randomized controlled trials as the gold standard. Reflecting
back on this experience, we observe that although the Dutch Health Research Foundation now
requests that applicants consider diversity issues in funding proposals, mixed methods proposals
receive both very positive and very negative peer reviews, meaning they seldom succeed.
Genomic medicine is advocating for more personalized medicine, and biomedical researchers are
studying the links between our bodies and minds, and how environments affect our genes (Hardon,
Manderson, and Cartwright 2016). New research methodologies such as citizen science projects are
emerging, if only to make better use of the big data sets increasingly accessible for analysis (see, e.g.,
Curtis-Robles et al. 2015). Nelson and colleagues (2014) have shown how the genomic turn in cancer
clinical trials is changing how trials are carried out. The heterogeneity in these more open-ended
trials provides an opportunity to produce novel biological or clinical insights. These developments
make randomized controlled trials which measure effects in general populations seem like an
outdated way of generating evidence (Stronks et al. 2013; Nelson et al. 2014).
Can global health experiments be part of more flexible systems of knowledge generation, where
different bodies of knowledge come together to provide understanding not only of the outcomes of
new interventions but also of the mechanisms through which they affect people’s well-being and
health? Emerging out of the quotidian experiences of translating knowledge generated in global
health experiments into practice, the articles gathered in this special issue illustrate the urgency of
taking context into account. Collectively, the authors examine the experiences of health workers and
users with new technologies, and point to the importance of local biologies (Lock 1993).
Janice Graham describes how African clinicians view a new Meningitis A vaccine, developed
through a partnership between the World Health Organization, PATH, the Meningitis Vaccine
Project, and the Serum Institute of India. While the vaccine reduced the incidence of Meningitis A in
the region, local clinicians are now witnessing a rise in other meningococcal serogroups. Graham
points out that the risk of such serogroup replacement was ignored in the communications
surrounding the Meningitis A vaccination program, and she suggests, “single outcomes chosen to
measure success are seductive, telling a partial story that is more complicated” (2016:14). In her view,
the Meningitis vaccine could have been more effective if global health researchers had been more
attentive to “the trends that locals recognize and experience” (15).
Thomas Cousins likewise points to the need to consider local experiences with new technol-
ogies, showing how recipients of antiretroviral treatment in South Africa complain about hunger
 MEDICAL ANTHROPOLOGY 449

when their viral loads decrease and their immune systems improve. While hunger can be
understood within the history of extreme socioeconomic inequalities in South Africa, novel
insights from neuro-gastroenterology help explain the experience of hunger. Cousins reveals
that the biological effects of AIDS medicines on guts and minds, and food (in)security, were
not accounted for, and that the drugs—proven effective in randomized controlled trials—fail to
work in situations of hunger.
Janina Kehr also reveals how medicines can be rendered ineffective when they do not account for
the precarious everyday lives of their intended users. Conducting field research in Seine-Saint-Denis,
she shows how of the 300 Roma patients diagnosed with tuberculosis (TB), only 10% were reportedly
cured: the majority of patients were forced to move away from the catchment area of the program.
The impossibility of curing Roma patients diagnosed with TB, due to forced evictions, was one of the
great frustrations of her interlocutor Carmen, a public health officer responsible for TB control in
the region.
In global health experiments, the experiences and frustrations of users and practitioners—such as
those in the South African antiretroviral therapy and French TB programs—are generally not
acknowledged as ‘evidence.’ The challenges that they experience in implementing these programs
are categorized as operational problems of health systems, not the efficacy of medicines. A more
open-ended and iterative approach to knowledge generation would require conceptual models of
efficacy that incorporate the social conditions in which patients acquire diseases, and account for the
power dynamics that shape the terrain in which global health technologies are used. This would
enable recursive learning of the situated efficacy of global health technologies, allowing for improve-
ments in their design.
Two other contributions to this special issue provide insights into research efforts that aim to
learn from local contexts and generate situated knowledge. Kay Felder, Ulrike Felt, and Michael
Penkler describe a research program in a Viennese hospital designed to provide evidence on the
long-term effects of bariatric surgery. The study is not designed as a randomized controlled trial but
as an observational study. While standardized instruments allow clinicians to learn more about the
effects of the surgery on patient health, the authors emphasize that the researchers do not provide
space for patients to share their stories about the contingencies and challenges of learning new ways
to eat. What is to be learned from practice has been predefined by local clinicians, with little room
for unexpected findings.
Angele Felipe in her contribution describes how clinical researchers in Portugal have developed
local instruments to diagnose attention deficit hyperactivity disorder (ADHD). She shows how the
translation of the category of ADHD into the Portuguese context “has entailed not only the
translation of [Diagnostic and Statistical Manual of Mental Disorders (DSM)] criteria into the
local clinical practice, but also the adaptation of other diagnostic protocols and questionnaires,
and the validation of clinical studies that indicate that ADHD is a disorder wider than the one
described by the DSM” (Filipe 2015:7). The divergence from the DSM definition, she argues, is
influenced by how parents and teachers in Portugal define the problem mainly in terms of
hyperactivity. Local clinical studies, using Portuguese instruments and definitions of ADHD, study
underlying neurocognitive pathways, thereby contributing to understandings of its local
manifestations.
The articles in this issue offer insights into the growing scope for anthropologists to team with
clinical researchers and epidemiologists to better understand both local etiologies of disease and the
complex mechanisms underlying the successes and failures of health interventions. The studies also
describe how different bodies of knowledge can come together to provide such understanding.
Combined, the contributions present cracks in the machine-testing model of evidence generation,
and point to research strategies that offer more iterative and open-ended knowledge generation. Can
we build on these enquiries to generate relevant ‘evidence’ on the complex interactions between local
biologies, political and social structures, and health?
450 A. HARDON AND R. POOL

Strategic collaboration, we argue, is necessary to break the hegemony of randomized controlled

trials in designing global health technologies and implementing health care. Anthropologists should
be attentive to changes in the epistemic practices of biomedicine, such as the smart trials being
developed by oncologists, microbiome or epigenetics researchers, and novel observational techniques
such as those utilized in citizen science health projects (Manderson, Hardon, and Cartwright 2016;
Curtis-Robles et al. 2015). Anthropologists can further align themselves with local clinical research-
ers and patient organizations confronting the limits of global evidence in practice. Perhaps we can
team up to develop new conceptual models and observational techniques and conduct ‘smart’ trials
that incorporate ethnographic and analytical studies to unravel complex interactions of local
biologies, attributes of health systems, social infrastructures, and users’ everyday lives, in the spirit
of the recommendations our team made to the Dutch Health Research Foundation a decade ago
(Hardon et al. 2016).
Together we could perhaps convince the captains of global health funding that significant
resources could be saved if they were not spent on highly standardized global health experi-
ments. Why not invest more in developing more comprehensive biosocial analytical frameworks,
in recursive learning and in designing smarter trials, with less time and resources lost trying to
find evidence that may not be useful—or as the articles gathered here suggest, applicable—
anywhere?
Strategic collaboration will not be easy. Tensions emerge when anthropologists wish to adapt
research designs halfway to account for new insights, when local clinicians point to complexities in
local disease manifestations, and when users present concerns not included in the original study
protocol. Accounting for complex mechanisms that affect health will result in unwelcome messages
such as persistent inequalities that are not easily resolved with a pill. Iterative learning requires that
researchers take responsibility for these unwelcome messages and advocate for global health pro-
grams sensitive to the complexities of local biologies and situated precarity.

Notes on contributors
Anita Hardon is professor of Anthropology of Care and Health, Research Priority Area Global Health, University of
Amsterdam. Her research interests include pharmaceuticals, youth, sexual and reproductive health, and multisited
ethnography and mixed methods research. She has received an Advanced Grant from the European Research
Council for the ChemicalYouth project (2013–2018). She is a co-editor of the Routledge Handbook of Medical
Anthropology.
Robert Pool is professor of Global Health, Research Priority Area Global Health, and chair of the Anthropology
Department at the University of Amsterdam. He has extensive experience in conducting nested ethnographies in
clinical trials. He is currently studying long-term care arrangements for the elderly and dying.

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