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Abstract

This article investigates what generates and sustains the centrality of accountability as an enduring motif of organizations and contemporary forms of organizing. The article uses a study of malaria interventions to explore the means through which accountability endures. First, the article engages with the burgeoning literature on accountability to explore the ways in which the continuing prominence of accountability is explained. Second, the article turns attention to interventions in malaria and specifically the production of accounts and distributions of accountability in this field. It will be argued that one means through which accountability has endured is through a heretofore un-discussed parasitism. Third, the contribution that parasitism can make to the academic literature on accounts and accountability will be considered. The article will suggest that it is the very features of accounts and distributions of accountability that enable such parasitism and that accountability becomes parasitic upon the organizational form.

Keywords

accountability ethnomethodology malaria parasites science and technology studies

Organizers of a stream at a recent major conference suggested that: ‘Accountability has emerged in recent decades as one of the distinct modalities of our times’.¹ Calls for accountability are made in relation to public and private sector organizations (One World Trust, 2007), politicians and political parties (Maer, 2010) and scientific (Smith, 1996) and technological developments (Lohmeyer et al., 2002). There are campaigns dedicated to enhancing, increasing or introducing forms of accountability (Accountability, 2010) and there is a burgeoning academic literature on this subject. The literature suggests that accounts and accountability taken together can involve the translation of diverse processes into a single financial figure (Miller, 2001), the ranking of organizations (Espeland and Sauder, 2007), targets that reorient organizational action (Strathern, 2002), the opening-up of opaque decision-making processes to greater transparency (Gray, 1992) and new markets for audit organizations and outputs (Mennicken, 2010). However, the same literature is clear that in place of any final reckoning on organizations, their outputs, decision-making processes or questions of responsibility, what we find are forms of accounts and accountability enduringly entangled with questions regarding the scope, veracity, integrity, shape, scale, outputs and consequences of accounts and accountability. Given this combination of pervasiveness and on-going questions, the article asks: what explains the endurance of accounts and accountabilities as features of organization and forms of organizing?

This question will be tackled by, first, engaging in more detail with the academic literature on accounts and accountability. Five explanations of the endurance of accounts and accountability will be offered. The article will then propose to explore a sixth explanation for the endurance of accounts and accountabilities; metaphorical and consequential parasites. Second, the article will introduce a study of interventions in malaria as an opportunity to explore parasitism in accounts and accountability. Malaria is focused upon as it contains significant challenges in managing interventions and intertwines accounts and accountabilities with numeric, economic and moral issues. Third the article will analyse the contribution that a focus on parasitism can make to the literature on accounts and accountability.

Accountability in the social sciences

There is a diverse and expanding literature on accounts and accountabilities. Initially this literature will be grouped into five explanations of the endurance of accounts and accountabilities. However, it should also be noted that these explanations overlap and intersect in various ways; this initial grouping should hence be considered as a heuristic device to aid our thinking about accounts and accountabilities.²

First, there are studies which explain the endurance of accounts and accountabilities through notions of efficiency. For example, Power (1997), suggests in his formative audit society argument that the motifs of audit have become essential conditions for meeting the aims of regulatory programmes. Drawing on and feeding into neo-Foucauldian writing on governmentality (Ericson et al., 2003; Miller, 1992; Miller and O’Leary, 1994; Rose, 1996, 1999) the suggestion is made that, for example, government policies (from assessing value for money in public sector spending, through to the ranking of university research outputs) provide rationales to be internalized by those subject to accounts and accountabilities. The extent and adequacy of take-up of the rationale then forms the basis of account assessment. This sets in train a program of responsibilization and individualization whereby subjects are expected to deliver on the terms of the rationale, whilst taking on the costs of doing so, allowing ‘authorities … [to] give effect to government ambitions’ (Rose and Miller, 1992: 175). For Foucault (1980) this provides: ‘A superb formula: power exercised continuously and for what turned out to be a minimal cost’ (1980: 158). Hence a first explanation for the endurance of accounts and accountability is its financial and operational efficiency.

Second, within much of the same literature, the endurance of accounts and accountabilities is explained through the structured necessity of repetition. That is, alongside efficiency, accounts and accountabilities become part of an ordered temporality of repeated assessment in, for example, performance measurements where the same organizations and processes are subject to accounts and accountabilities at set intervals in order to render the organization assessable (Power, 1997; Rose, 1999; Rose and Miller, 1992). For Pentland this repetition forms audit rituals which have: ‘succeeded in transforming chaos into order’ (1993: 606). In particular, accounts and accountabilities have introduced a ‘ritual which transforms the financial statements of corporate management from an inherently untrustworthy state into a form that the auditors and the public can be comfortable with’ (1993: 605). Accounts and accountabilities endure because they have become a ritualized and repetitive expectation.

Third, accounts and accountabilities are noted as expanding into new territories, new types of organization, presenting new opportunities for carrying out the same procedures (see for example Osborne and Rose (1999) on the expansion of governmentality; also see Ferguson and Gupta (2002) on the creation of the individual as auditor of their own ‘firm’).³ Accounts and accountabilities endure through the discovery of new locations in which to work.

Fourth, there is literature that considers the utilization of accountability in portrayals of organizational identity. For example, accounts and distributions of accountability can be seen as part of an organization’s market positioning as transparent and open, as ethical, as taking corporate social responsibility seriously (Drew, 2004; Gray, 1992, 2002; Neyland, 2007; Shaw and Plepinger, 2001). Accounts and accountabilities endure through their centrality in organizations’ market positioning.

Fifth, there are alternative ways of conceiving the entanglement of markets, accounts and accountabilities. For example Mennicken (2010) looks at the ways in which auditors seek to generate markets for their activities. Alternatively, the outcomes of forms of accounts and accountabilities become market-oriented assets in their own right, as is the case with media organizations promoting their league tables as one way to attract custom (such as the Financial Times MBA rankings, see Free et al., 2009). Accounts and accountabilities endure as they produce marketable assets.

These five explanations provide some grounds for exploring the endurance of accounts and accountabilities and they are each convincing in their own ways. However, this article will now suggest an alternative; that the very features of mechanisms of accounts and accountabilities lead to an on-going parasitism that feeds the production of ever more forms of accounts and accountabilities. The argument will be made that the mechanisms and outputs of accounts and accountabilities provide the basis for ever more questions of accounts and accountabilities, rendering the latter parasitic on the organizational form.⁴ In place of accountable certainty comes inconcludability. In order to explore in more detail, first, mechanisms of accounts and accountability and, second, inconcludability this article will turn attention to ideas from science and technology studies (STS) and ethnomethodology.

In STS research—particularly research which can be said to draw its ideas from actor-network theory (ANT)⁵—there has been a recent turn towards research on organizational devices and mechanisms (with a particular focus on markets; see for example, Callon, 1998; Callon et al., 2007; MacKenzie et al., 2007). The work of Callon (1998) has established a particular and challenging set of ideas for understanding markets as assemblages of people, things and relations between. This work has engaged debates in economic sociology (Granovetter and McGuire, 1998), the anthropology of markets (Slater, 2002) and within STS as a discipline (Woolgar et al., 2009). This STS turn towards economic and organizational mechanisms has raised challenging and provocative ideas focused on what counts as a market actor (Cochoy, 2009), market assemblages (Sjogren and Helgesson, 2007), overflows (Callon, 2007), politics (Barry, 2002), trading (MacKenzie, 2009) and notions of quality (Callon et al., 2002).⁶

A key focal point in this research has been on notions of value, valuation and its consequences. For example, MacKenzie (2009), suggests in his study of the on-going production of carbon markets and carbon trading that the inculcation of values (of credits, trades, etc.) into the carbon market assemblage provides a consequential basis for making things the same. That is not to say that entities are literally rendered equal, but rather that forms of valuation (including, for example, monetary value) provide a basis for assessing relative equivalence.

These ideas of assembling and valuation have also been incorporated into analyses of accounts and accountabilities (see for example Hopwood (2009)) on calculative devices in accounting and Skaerbaek (2009) on audits, framing and overflows). In this approach accounts and accountabilities are understood as assembled mechanisms through which organizations, outputs, decisions and processes are accomplished. Assembled mechanisms of accountability are said to establish demarcations, boundaries, what will and will not be counted. For example, Law (1996) suggests that organizational account production work involves: ‘an active process of blocking, summarizing, simplifying and deleting … [which decides] what is to count and what, therefore, becomes counted’ (1996: 291). Law and Mol (1998) talk of this distinction between what gets to count and what does not as the outcome of ‘a labour of division’, (1998: 23) enabled through ‘technologies of calculation’, (1998: 27). Hence a first sensibility⁷ in this article will be to interrogate the assembly and demarcation work that goes into establishing what counts and what gets discounted, valued and devalued, in distinct moments of accounting and distributing relations of accountability. In doing so, the article will also interrogate the kinds of account production technologies or devices which contribute to demarcation. The article will explore to what extent the assembled mechanisms of accounts and accountability enable parasitism.

A second focus in the analysis will draw in ideas from ethnomethodology. In ethnomethodology (Garfinkel, 1967; Luff and Heath, 1993; Lynch, 1998; Suchman, 1993) there has been a focus on the account-able, with everyday forms of interaction such as conversations analysed as face to face and moment to moment exchanges through which sense is actively and accountably accomplished for the practical tasks to hand. As Garfinkel suggests:

Any setting organizes its activities to make its properties as an organized environment of practical activities detectable, countable, recordable, reportable, tell-a-story-about-able, analyzable—in short accountable. (1967: 33)

Heritage suggests that Garfinkel’s concern is ‘directed at examining how various types of social activity are brought to adequate description and thus rendered ‘account-able’ (Heritage, 1984:136). Hence a turn in conversation becomes account-able in being open to sense-making assessment. Importantly for this article, any turn in a conversation provides the basis for further questioning or assessment in the business of making sense. In this approach, a conversational turn is taken to be an account. Such accounts are, in principle, inconcludable in that each turn can be opened for further assessment and account production. In this way each new turn in a conversation is open to the same sense-making enquiries which rendered previous turns account-able. For Garfinkel (1967) what renders practical action conceivable is the invocation of an etc. clause through which recognition is paid to the possibility of further questioning and further questioning ceases in order to get on with the matters at hand. The accomplishment of an account-able sense is considered good enough in that it enables practical action to continue and for a sense to be made of that practical action. This article will explore the extent to which inconcludability can provide a second sensibility for analysing parasitic accountability.⁸ The article will explore the possibility that the properties of each new account provide the grounds for further questions of accountability (a form of parasitism with accounts feeding off accounts and the organizational forms that produced them) with no mutually recognized, agreed-as-adequate etc. clause in place. The article will now turn attention to a study of malaria in order to assess the utility of these two sensibilities for analysing the endurance of accounts and accountabilities.

Malaria methodology

The material drawn on in this article comes from a study of interventions in malaria. Although I usually favour an ethnographic approach to research, in this particular study I was trying to engage with the complexities of malaria interventions which are multiple across organizations, times and geographical spaces. It seemed implausible to ethnographically engage with the number of locations in which malaria interventions were made.⁹ Instead, I designed an interview-based study of 34 organizations. These included pharmaceutical firms, philanthropic funders, state and super-state actors, members of public private partnerships, consultants, university scientists and advocates of different interventions. The interviews were conceived and navigated drawing on a set of methodological prerogatives similar to those utilized in constructivist laboratory ethnographies (see for example, Latour and Woolgar, 1979); the aim was to give participants the opportunity to discuss and reflect on the complex science of malaria and analysis was carried out in a symmetrically sceptical manner. In line with the latter, no particular interviewee was accorded greater status or noted as the bearer of the ‘truth’ of the matter being investigated and instead the multiplicity of ways of conceiving of the matter of concern (Latour, 2004) is presented in the subsequent analysis.

In order to achieve the analysis, the interviews were analysed in an exploratory manner. In place of a discourse analytic approach to interviews (see for example Potter and Wetherell, 1987/2005) whereby data is transcribed, coded and analysed and grouped into representative ways of talking (discourses), in this approach the data was transcribed and then grouped according to emergent themes (for example what was said about interventions (vaccines, mosquito nets and medicine), what was said about funding (philanthropic, state, private sector), what was said about evaluations, and so on). The overall aim was not to produce a singular coherence in the discussions of these themes, nor to evaluate who held the truth, but instead to draw together and analyse the multiplicity of ways of conceiving of the themes being discussed. In order to encourage detailed reflection on the state of malaria, interviewees were guaranteed anonymity, the interviews remained largely unstructured and the time taken for interviews varied from 45 minutes to several meetings over several days. At every opportunity the researcher sought to combine interviews with a guided tour of the interviewee’s workplace in order to gain access to a richer picture of their work and a variety of supporting materials were drawn together from the scientific literature and popular media representations of malaria.¹⁰ In the following analysis, these materials will be drawn together, but no greater truth-status will be accorded to any particular source.

Malaria analysis

Assembly work (part 1)

Drawing on the first proposed sensibility we can say that interventions in malaria require assembly work. Assembling in this case involves both elucidation of the terms on which entities enter an assemblage (on Callon’s terms a disentangling of entities from their relations external to the assembly) and the nature of relations to be understood as enabling and maintaining the connections between entities as a more or less coherent assemblage for intervention (what we might refer to as shifting entities into internalities). Assembly work of this kind in the field of malaria happens most coherently in scientists’ attempts to procure funding for interventions in malaria and in their proclamations of scientific results partly designed to retain funding (see below). Building an initial assemblage (a description of a malaria intervention) and building the value of that assemblage (gaining and retaining funding) are thus indistinct.

We should not assume too rapidly that there is only one way to assemble a malaria intervention. Most descriptions of malaria feature a cyclical parasitic tale in which the mosquito carrying the parasite bites the human, the saliva from the mosquito allowing the sporozite to enter the bloodstream where the parasite multiplies in the liver and is then carried through the body on red blood cells, causing fever, coma and sometimes death. Other mosquitoes biting the human after infection can then become carriers of malaria and infect others. However, different sets of entities, relations between and forms of value are accomplished in distinct ways of assembling the disease and interventions into the disease. Hence vaccinologists may bring t-cell responses or prime boost strategies to the fore, placing a value on disentangling the inner workings of the human body (organs, immune system, blood, parasitic mutations, even neurology on occasions (National Geographic, 2007; VOA, 2005)). Advocates of mosquito nets bring the lifestyles and feeding habits of mosquitoes and the sleeping habits of people, amongst other things to the fore (RBM, 2005). And those seeking environmental interventions will bring mosquito breeding, agriculture and domestic dwellings (ABC, 2007), larva eating fish (Observer, 2008), insecticidal sprays (Wall Street Journal, 2006; WHO, 2006) and/or livestock (BBC, 2001; WHO Bulletin, 2001) to the fore. Building an assemblage (for example, vaccinologists’ funding bids) thus involves bringing to the fore certain entities (such as parasites, the immune system), disentangling these entities from their relations external to the assemblage (for example, parasites are to be described in specific terms for this bid, as having certain characteristics, intent and operating in certain ways) and re-entangling the entities internal to the assemblage (with the relation between parasites, their articulated characteristics and the immune system, for example, to be given specific narration in relation to the specific vaccine candidate in focus). This is just an indication of distinct acts of assembly (for more interventions, see Oxfam, 2003). In different regions of the world, distinct mosquitoes are brought to the fore (Anopheles gambaie and Anopheles arabiensis in Africa and Anopheles stephensi and Anopheles culicifacies in Asia). In some assembly work, only one species of mosquito (Anopheles gambaie) is said to prefer humans to livestock (FARM-Africa, 2005). In other assemblages, different strains of malaria (plasmodium falciparum, p. vivax, p. malariae and p. ovale) are focused on, with plasmodium falciparum positioned as the most lethal and most commonly found in Sub-Saharan Africa.

Bringing entities to the fore through disentanglement and re-entanglement into assemblages also involves preparing entities for the rigours of valuation. Assembly work involves building value into the assemblage and denoting consequential value (for example by assessing the costs of malaria for sub-Saharan Africa—often said to be around $12b or around 40% of public health spending—that the assemblage would alleviate; GSK, 2005). Each of these assemblages has also been accompanied on occasions by forms of disassembly, with vaccine trials showing low or no efficacy (Gates Malaria Partnership, 2006), mosquito nets being used for fishing (Githinji et al., 2010) and environmental interventions questioned for their consequences.¹¹ Thus value is no more than speculative (in the sense that the value of an assembled intervention is to be accomplished).

If funding were limitless, the suffering less acute or the scale of death less significant, perhaps assembly work, valuation and intervention decisions would be less fraught. However, despite state government and philanthropic funding increases from the 1990s onwards, there are still limited amounts available, there are said to be 300 to 500 million cases of malaria per year, with one to two million deaths and around 90% of deaths occurring amongst the poor of sub-Saharan Africa, with around 90% of these deaths in children under the age of five (see Bayer, 2006; Gates Malaria Partnership, 2006; National Geographic, 2007; POST, 2005; VOA, 2005). What makes accounts and accountabilities in the field of malaria so challenging is that assembly work, speculative valuation, scale and a moral imperative¹² go hand in hand.

Assembling the disease, bringing particular entities to the fore through disentanglement, providing clarity in the connections between those entities and the alleviation of suffering, become ways in which potential malaria interventions enter into processes of valuation, establishing what will and will not be counted. However, money is not simply attached by a state government or philanthropic source to a particular assemblage. Instead, the assemblage is broadened to include assessors (auditors, oversight committees, advisory boards) and objectives are proposed (a translation of consequential value—how a particular intervention will deliver a particular kind of alleviation to a suffering population—into benchmarks, end-points, markers of success). This in turn enables the relations between entities to be set in place, with forms of valuation carried out (through metrics such as performance indicators, included in reporting mechanisms) and the assemblage incorporated into an organizational form through which money can be distributed and (to an extent, on occasions, see below) comparisons to be drawn between assemblages. Or alternatively the assemblage does not attract funding, crumbles or is re-assembled and new attempts are made to draw in investment. For the valued assemblage, the most common form of organization through which money is distributed and assessments made amongst the entities articulated, is the Public Private Partnership.¹³

Assembly work (part 2)

Public private partnerships (PPPs) are brought into being in various forms. As assemblages, these partnerships are characterized by different kinds of structures, through management by intergovernmental agencies or management by a separate legal entity, having independent legal status, or operating more like an informal collaboration, owned by the public sector but with private partners or hosted by an agency/NGO or orchestrated by a company (Nishta, 2004). PPPs also bring to the fore different ways of orienting malaria as primarily involving problem solving (Buse and Waxman, 2001), the reduction of global disparities (Sundaran and Holm, 2006), a need for product development, advocacy or donation programmes (Walt, 2001), improved access to healthcare products, global co-ordination mechanisms, strengthening health services, public education or regulation and quality assurance (Nishta, 2004).

As organizational assemblages, they become the focal point for co-ordinating the previously assembled interventions into malaria. Hence within PPPs we can find a multiplicity of assemblages, including the PPP itself and various interventions the PPP is managing. ‘Managing’ in this case can involve co-ordinating and/or distributing value through, for example, vaccine interventions (Malaria Vaccine Initiative PPP) or mosquito net distribution schemes (Roll Back Malaria PPP). Central to the work of PPPs is not just to attach value to interventions it manages, but to build systems of account (how much value, given through what phases, valued how often, using what objectives to set metrics, benchmarks, etc.) and accountability (distributing responsibilities amongst entities in the assembled intervention and in the PPP for doing valuation and measuring derivation from objectives) into the assembled intervention. Drawing on our first sensibility, PPPs establish what will and will not be counted and as a result funded interventions thus accrue a system of value (objectives, measures, relations, temporality), not just an amount of money. Funding bodies (state and philanthropic) look to use PPPs to pool resources and manage the speculative (risky) nature of placing value in interventions by giving value to more than one intervention and juxtaposing interventions through further aggregate comparative valuations:¹⁴

Interviewee 9 (UK government agency)

We like [partnerships] because they are a good way of managing risk because of their portfolio of activities and their scientific expertise … we don’t have that scientific expertise to manage all those tasks. Because they’re managing a portfolio they’re able to distribute their risk across different candidates … going forward with one product is a big risk and we’re not keen on those and as a donor you bear the expense yourself.

However, PPPs are not straightforward and stable assemblages. For example, the terms of the partnership have proven problematic with assembled entities experiencing uneven distributions of opportunity for participation (Buse, 2004; Hardon, 2001; Hayes, 2001; Rundall, 2001; Widdus, 2003). Further, working relationships in PPPs have had problematic consequences for particular interventions (Chataway et al., 2005; Nishta, 2004; Sundaram and Holm, 2006), there has been an uneven distribution of information among entities (Buse, 2004; Caines and Lush, 2004; Oehler, 2004) and providing governing oversight of an assembled and valued partnership has proven problematic (Buse, 2004).

It is within these problematic and uneven PPP assemblages, that particular interventions (having already been the focus for assembly work) move into the field of malaria, are given a value (tied to a form of accounting) and set of responsibilities for value (relations of accountability). This will be further illustrated by drawing on an example. There is not the space in this article to detail all the various interventions which are currently made into malaria (across different vaccine candidates, medicines, environmental interventions and mosquito net distribution schemes with attendant education initiatives). Instead the current leading malaria vaccine candidate will be focused on.¹⁵

The PPP which manages the leading candidate is the Malaria Vaccine Initiative (MVI).¹⁶ MVI was set up in 1999 via a grant from the Gates Foundation. It is managed through the Program for Appropriate Technology in Health (PATH). PATH has an annual budget of over $250m, from philanthropic sources (such as the Gates Foundation), state governments and via industry collaborations (with pharmaceutical firms such as GSK). Around 30% of PATH funding goes into vaccine projects and MVI manages around 15 vaccine projects at any time. PATH’s funding is dependent on forms of accounts and accountability, as is MVI’s funding from PATH, as is funding for each vaccine project funded and managed by MVI. The leading malaria vaccine candidate has been in development for over twenty years. During that time, the assemblage of entities, the particular values brought to the fore or pushed to the background, the system of assessment, benchmarks, measures and indicators have all shifted many times. The subsequent analysis due to space constraints will focus on the recent and current trials of the leading vaccine candidate.

After 20 years of development there is still no vaccine ready for use. Vaccinologists attribute this temporality to the complexity of parasitic diseases generally and the malaria parasite in particular. For example, the Walter Reed Army Institute of Research in the US, which has been involved in malaria interventions over several decades, point out: ‘There has never been a vaccine against an organism this complex; there has never been a successful human vaccine against a parasitic disease’ (VOA, 2005: 1). Many of the interviewees who took part in this research reflected on similar concerns:

Interviewee 18 (Malaria PPP)

… all diseases are not the same in terms of making vaccines in terms of their complexity. Most vaccines in the past were made by a kind of an opportunism; you just try something and it works. We’re trying to be a little bit more directed about this but, to a certain extent, we’re still doing the same thing with a much more complicated organism.

The happenstance history of vaccines received frequent re-telling by interviewees who hoped for similar beneficial circumstance in dealing with the malaria parasite. However, happy happenstance, multi-million dollar budgets and the lives/deaths of millions of children make for uncomfortable bedfellows. Add in the possibility of placing value in other kinds of interventions (mosquito nets, medicines, environmental controls) and the moral weight of malaria is made manifest in discussions of the appropriateness of giving value to vaccine assemblages. For some interviewees giving value to vaccines involves taking value away from other assembled interventions:

Interviewee 2 (Senior neglected disease scientist)

I see malaria vaccine as taking money away from areas that we know work to something which is entirely speculative. I’m just a bit cautious about that … It’s a really serious issue … [The current leading malaria vaccine candidate] will never achieve anything at all in Africa.

However, there was no universal agreement with these negative views of vaccine valuation. For the following interviewee, it ought to be possible to produce a vaccine:

Interviewee 3 (US government agency)

We also know, based on the … experience [of the current leading malaria vaccine candidate], that here you have a novel synthetic vaccine that gives you at least partial immunity and so, you know, if you take all of these things together, I think that the overwhelming impression is that technically it should be feasible to come up with a malaria vaccine.

Placing value in the leading vaccine candidate, taking money away from areas that work, for something perhaps uncertain but that ‘should be feasible’, provides the basis for developing systems of: value (accounts) and responsibilities for values (relations of accountability). Such accounts and accountabilities are articulated as the means by which assemblages will be judged, funding continued or ceased, increased or decreased. In other words what gets to count and what does not, involves an entanglement of numeric, financial and moral values. However, in place of providing certainty, this article will argue that these entanglements provide the grounds for inconconcludability and parasitic accountability.

Efficacy and Inconcludability

A key form of value is derived from efficacy rates. Broadly speaking, efficacy rates are measured during vaccine trials where a specific population are given a vaccine candidate and then the number within that population that develop malaria within a set time period are measured and also measured against a non-vaccinated segment of the same population. Efficacy rates can be measured in laboratory trials¹⁷ or in field trials. The current leading malaria vaccine candidate is involved in large scale, phase three field trials. The vaccine candidate is said to demonstrate an approximate efficacy rate of 30% in children under five as the following interviewee reflects:

Interviewee 1 (Clinical trials manager, sub-Saharan Africa)

[the leading malaria vaccine candidate] has shown reasonable protection against the amount of malaria kids get. 30% less malaria that children get in a season following the [dose of the leading candidate] vaccine.

Within the back and forth discussions of the kinds of assembled interventions which ought to be valued, 30% has become a central figure as the following two interviewees suggest:

Interviewee 1 (Clinical trials manager, sub-Saharan Africa)

So [the leading vaccine candidate] it’s encouraging but it’s not brilliant. The 30% figure is quite important because we see about a 30% reduction in malaria in children sleeping under bed-nets. So what we’re looking at at the moment is a vaccine that’s about as effective as sleeping under a mosquito net. So is it worth it? Lots of people say no, but if you vaccinate kids then it’s done and that’s less than having to educate populations about bed-nets making sure they haven’t got holes and so on.

Interviewee 4 (European based PPP)

But there is no vaccine in the world, none whatsoever, which has an efficacy that’s below 80%, most of them 90%, so why should you go for a 30% efficacious vaccine for the poor in Africa? That’s simply a double standard, you can’t do things like that, that’s immoral in my view. I dare not say it loudly when the [pharmaceutical firm] board member is around but I whisper it in his ear from time to time.

Interviewee 1, when talking of 30% made her hands into fist shapes, the left hand acted as representative of the vaccine, the right hand moved alongside the left representing the bed-net. Interviewee 4 drew a dot close to him on a sheet of paper representing vaccines for other diseases and drew another dot at the other end of the article representing the malaria vaccine candidate. I understood these words, gestures and annotations to show that the 30% efficacy rate established particular and informal lines of equivalence.¹⁸ However, these lines are used to draw distinct conclusions. For Interviewee 1, the vaccine candidate can be drawn into relations of equivalence with other interventions in malaria. On these terms the vaccine is more or less as successful¹⁹ as other interventions.²⁰ For the second interviewee the 30% efficacy rate for the leading candidate enables a line of equivalence to be drawn with other successful vaccines for other diseases. Interviewee 4 suggests 80 and 90% efficacy rates for other vaccines acts as a demonstration of both the failed science and failed morality of the leading vaccine candidate. This begins to suggest, drawing on our second sensibility, that the complex assembly work involving funders, PPPs and particular interventions designed to produce outcomes such as 30%, do not produce narrow, numeric certainty, but rather set the grounds for the production of further competing accounts. In place of concluding answers to questions regarding the value of this intervention, come questions regarding the entanglement of economic value and moral value: is 30% (a) good value? 30% provides a basis for parasitically feeding other accounts, calls for accounts and questions of accountability.

Prior to pursuing this parasitism in further detail, it should be noted that the discussion thus far has somewhat simplified efficacy rates. Efficacy is not a single measure, but a distribution of values which stem from the objective to figure out the extent to which the vaccine candidate can reduce suffering and hence the extent to which this assembled intervention ought to accrue more value (for example from PPPs such as MVI via philanthropic funders). These values form a system of accounting for the intervention. Hence values are placed on number of cases of malaria in laboratory and field trials, in different age groups (children under five are brought to the fore), different genders (pregnant women are particularly important as their immune systems raise further questions of efficacy) and in different regions. Further values can be placed on cost of a vaccine candidate (for example, intellectual property issues could potentially increase dosage costs) and the requirements for delivering a vaccine candidate (for example multi-stage vaccines could cost more and require a delivery and surveillance infrastructure). This distribution of values also forms a system for accountability—responsibilities for doing counting and attributing values to forms of counting are distributed. Principal and secondary investigators, vaccine candidates, laboratories which have advocated and received funding for candidates can all be held responsible (and decisions taken on their future value) in relation to the attribution of value. As the following interviewee suggests, there can be 1, 2 or 25 values in place and multiple accountabilities.

Interviewee 4 (European based PPP)

We’ve also learned from … trials that it’s enormously difficult on a scientific basis to define the outcome, what do you want from your vaccine? What is it you expect from your vaccine? Now if you are an industrialist and seasoned in the game, you’re having one or two objectives and then you have 25 exploratory objectives because then you will always hit something. So it was one of the exploratory objectives that satisfied the criteria when [the leading malaria vaccine candidate] moved on [in recent trials], it’s not the original objectives. So it’s a lesson for all of us how difficult it is. It is a difficult area.

These values can be used to derive multiple lines of equivalence, both internal (for example, drawing equivalence assessments between age segments of a trial population) and external to the assemblage (for example, drawing equivalence assessments between this vaccine candidate and another vaccine candidate or, more likely, between this vaccine and another intervention).²¹ Although multiple objectives, measures and putative lines of equivalence can be given a value initially (as primary or secondary/exploratory values, reflecting a perceived importance in terms of ranking the measure and the vaccine candidate and providing the kinds of information which might help justify future funding), values can shift, lines of equivalence can move up and down a notional ranking as interventions are rolled out and decisions over the initial value to place on an objective or a line of equivalence are made, reviewed and made again. In this way, the relative importance of an objective and the line of equivalence to which it might contribute are also subject to an on-going inconcludability:

Interviewee 3 (US government agency)

… in the [recent] trial, because it was a larger trial that involved something like 1,600 children, it had the opportunity to look at severe disease as a secondary endpoint. So the study was not actually powered based on that. So it wasn’t that they necessarily set out to look at that [severe malaria in children] as a primary endpoint and that he had enough participants to do that, but, as it turned out, they were able to achieve a statistically significant, or demonstrate a statistically significant reduction in the incidence of severe disease of around 58% that was, you know, that was not, as I said, it was not a primary endpoint but it turned out to be statistically significant.

Interviewee 3 reflects on the results of the recent field trial which demonstrated unexpected results in a heretofore neglected (secondary or exploratory) objective; the efficacy rate in terms of reducing severe cases of malaria in children under five. The initially low priority for this objective may be attributable to assumptions regarding the way the vaccine would work (it would either stop malaria or not, rather than it would limit the severity of malaria) and an assumed equivalence of the relation between the vaccine and different trial age groups. However, as 90% of deaths from malaria in Sub-Saharan Africa are said to be in children under five, finding a value as high as 58% for this secondary objective, pushed it to the forefront. It was a prime economic value (58% perhaps being utilized in lines of equivalence drawn up with, say mosquito nets, which (may) remain at 30%, suggesting greater value from the vaccine candidate) and a prime moral value (the most likely to die, most vulnerable members of the population—apart from pregnant women—were at the centre of this value). Its shift from secondary endpoint to headline news reflected this new importance.²² However, as the previous interviewee continues, this requires further scrutiny:

Interviewee 3 (US government agency)

The obvious question with that is, is this a statistical fluke? Will it hold up in subsequent trials if under similar epidemiologic settings? And will it hold up in different epidemiologic settings?

The results of accounting for malaria (attributing values to particular objectives) and ranking different lines of equivalence (suddenly figuring out the equivalence or not of different trial age groups becomes vital), enables value to be attributed to and demonstrated in the vaccine candidate, the lab which has done the work, the field trial site, the principal and secondary investigators and the financial supporters. There is a multiplicity of values (numeric, economic and moral) and producing notional rankings of values manages this multiplicity. However, this is not straightforward. The complex assembly work to produce a numeric value introduced further questions of the accounting mechanism (for example, could the 58% result be achieved in other locations), the relative priorities held by the initial trial (for example, why was severe malaria an exploratory objective? Did this objective move up the rankings just to accrue more value?) and numbers of population incorporated into the trial (for example, were enough severe cases counted, given that this was initially an exploratory objective?). The very features of accounts and accountability formed the basis for its inconcludeability; as information was accounted, questions of that information were raised, leading to parasitic accountability.

The 58% figure, rather than concluding questions of efficacy, raised further questions. For example, scientists suggested that a trial of bed-nets in Zambia, Ghana, Rwanda and Ethiopia resulted in up to a 66% reduction in malaria (WHO, 2008), shifting again the relative equivalence of bed-nets and vaccines. The following interviewees also reflected on this difficulty of values, accounts, accountabilities and inconcludability:

Interviewee 6 (Sub-Saharan Africa based PPP scientist)

How do you assess something [economically] that can really save people’s lives?

Interviewee 18 (Malaria PPP)

… our ability to be able to make a 100% vaccine is probably non-existent.

For interviewee 6 the numeric, economic and moral value of the vaccine candidate can only be understood as an on-going accomplishment; it remains inconcludable. For Interviewee 18 this inconcludability is in principle without end. The parasite is likely to change in relation to the human body, its environment and any intervention made into either of those entities. Such inconcludability provides the basis for parasitism, with questions of accounts, calls for new accounts and distributions of accountability resulting from the production of efficacy rates like 30% and 58% (and any subsequent rates and rankings that might be produced), the drawing of multiple lines of equivalence with other interventions and the moral imperatives at stake.

Discussion and conclusion

In the case of malaria interventions, accounts, accountabilities and lines of equivalence do not introduce numeric, economic or moral certainty. Instead speculative judgements are made on values, objectives and associated metrics, lines of equivalence, their ranking and so on. All investments are speculative as all investments are based on assumptions of the possible, potential, yet to be achieved or measured equivalence between entities. In this case the economic line of equivalence (value) has proven impossible to disentangle from the moral weight of malaria (good value). The immediacy of the problem, poverty and the scale of death among children continue to provide the grounds for justifying and challenging every (inevitably) speculative, inconcludable account and concomitant investment. These lines of equivalence remain speculative and systems of account (translating objectives into a range of indicators) and accountability (distributing responsibility for valuation), provide one means through which speculation is navigated. The consequences for those suffering from malaria is that all accounts remain inconcludable as all interventions attempt to weave together the numeric (indicators), economic (value) and moral (good value). Further accounts, calls for further accounts and accountabilities and declarations of the failure, limitation or immorality of interventions, parasitically feed off the accounts and accountabilities produced.

Parasitism has been drawn on in this article using ideas from STS and ethnomethodology to explore a sixth explanation for the endurance of accounts and accountabilities. Alongside efficiency, ritual, new locations, organizational marketing and marketable assets, parasitic accountability has been introduced as a means to engage with the ways in which each new account provides resources from which other accounts and accountability processes can parasitically feed. Miller suggests that: ‘The calculative practices of accounting have one defining feature that sets them apart from other forms of quantification: their ability to translate diverse and complex processes into a single financial figure’ (2001: 381) and ‘what is counted usually counts’ (2001: 382). In contrast this article has suggested that in some instances of accounts and accountabilities, there is no single figure produced (for example, the 30% efficacy rate for the leading malaria vaccine candidate was produced alongside a series of further, secondary indicators such as 58%) and the range of figures produced are joined with further figures (for example the 30% and 66% efficacy rate for bed-nets) and a broad range of further questions (numeric, financial and moral) in competing accounts and accountabilities. These competing alternatives parasitically feed off the initial accounts and the organizational forms that produce them.

In developing this parasitic approach to accounts and accountabilities the article has argued that STS notions of accounting mechanisms, assembling and demarcating what is to count and what will not be counted can provide a useful set of ideas for interrogating the ways in which accounts and accountabilities draw various people, things and relations together and make them work. The STS vocabulary provides a basis for bringing the detail of, for example, assembly work in PPPs to the fore while also encouraging us to consider what else is pushed to the background. The vocabulary also gives us ways to think about and articulate the continual fluctuations in the make-up of assemblages.

Drawing in ethnomethodological ideas on inconcludability has opened up further possibilities for analysis. Although ethnomethodologists suggest all occasions of accountability are subject to an in principle inconconcludability, most questions of accounts cease through the invocation of an etc. clause via which further questions are not asked in order to get on with the practical matters at hand. In the case of malaria the absence of an agreed-as-adequate etc. clause leads to on-going questions and the absence of any satisfactory conclusion to accounts. This focus on inconcludability is useful for drawing our attention to the diversity of uncertainties that accounts and accountability can generate. The notion of the etc. clause provides us with one means to navigate between the presence and absence of certainty in account and accountability processes, drawing our attention to the topic of where and when questions of accounts, accountability and value start and stop.

Taken together the STS and ethnomethodological sensibilities provide a basis for understanding the ways in which accountability can become parasitic upon the organizational form. The multiplicity of account and accountability mechanisms (in the case of malaria various PPPs and interventions) provide a variety of accounts (such as efficacy rates) and accountabilities (distributions of responsibility for the accounts). Certain accounts (in particular the 30% and 58% efficacy rate) are taken up across the field and questioned in terms of their content (accuracy, reliability, statistical significance), who produced them (who is accountable) and their financial (is 30% efficacy worth hundreds of millions of dollars) and moral (could this money have been spent elsewhere?) implications. Each of these questions of accounts and accountabilities, the drawing together of alternative accounts and calls for further accounts and accountability parasitically feed off initial accounts. Accounts and accountabilities endure through this parasitism.

Footnotes

Notes

Biography

Dr Daniel Neyland is a Senior Lecturer at the Department of Organization, Work and Technology, Management School at Lancaster University. His research interests cover issues of governance, accountability and ethics in forms of science, technology and organization, drawing on ideas from ethnomethodology, science and technology studies (in particular forms of radical and reflexive scepticism, constructivism, Actor-Network Theory and the recent STS turn to markets and other forms of organizing) and his research is ethnographic in orientation. Address: Department of Organization, Work and Technology, Management School, Lancaster University, Lancaster, LA1 4YX, UK. Email: d.neyland@lancaster.ac.uk

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Parasitic accountability

Abstract

Keywords

Accountability in the social sciences

Malaria methodology

Malaria analysis

Assembly work (part 1)

Assembly work (part 2)

Interviewee 9 (UK government agency)

Interviewee 18 (Malaria PPP)

Interviewee 2 (Senior neglected disease scientist)

Interviewee 3 (US government agency)

Efficacy and Inconcludability

Interviewee 1 (Clinical trials manager, sub-Saharan Africa)

Interviewee 1 (Clinical trials manager, sub-Saharan Africa)

Interviewee 4 (European based PPP)

Interviewee 4 (European based PPP)

Interviewee 3 (US government agency)

Interviewee 3 (US government agency)

Interviewee 6 (Sub-Saharan Africa based PPP scientist)

Interviewee 18 (Malaria PPP)

Discussion and conclusion

Footnotes

Notes

Biography

References