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This introductory chapter explains why evidence-based medicine is important. The sluggish incorporation of medical evidence into clinical practice is a concern for three key reasons: safety, quality, and the efficiency of resource allocation. First, the delivery of unproven care can expose patients to serious risks. Second, the slow integration of evidence can lead to suboptimal outcomes for patients who receive treatments that work less well for their conditions than alternatives. Third, the failure to implement evidence-based practices encourages wasteful spending, causing the health care system to underperform relative to its level of investment. This book assesses whether the delivery of medical care in the United States is evidence based. It argues that by systematically ignoring scientific evidence (or the lack thereof), the United States is substantially out of balance.

This chapter focuses on the evidence-based medicine (EBM) reform project. Ultimately, if the EBM project is to realize its aspirational goal to improve the quality and efficiency of U.S. medical care, it is necessary but insufficient for research agencies like Patient-Centered Outcomes Research Institute (PCORI) to endure. In the long run, patterns of medical governance must change. PCORI (or whatever entity succeeds it) must develop a reputation among key stakeholders for competence, relevance, and impact that causes policy makers to conclude that supporting EBM is in their own political interest. The chapter then draws on lessons from the literature on U.S. state building to develop strategies to increase the durability of medical governance reform in contemporary American politics. It also briefly reviews the challenges of political sustainability that face any new agency or policy.

The fourth chapter turns to works by Pauline Melville and Elizabeth Nunez to explore how breast cancer and anorexia nervosa offer physical and emotional renewal for the protagonists. In The Migration of Ghosts, Boundaries, and Anna-In-Between, Melville and Nunez use their characters to question body-image ideals. The works attest to the life-altering impact of disease. The protagonists’ illnesses, rooted in their dis-ease with their bodies, their relationships, and their privilege, highlight the emotional side effects that can accompany physical maladies. In Melville and Nunez’s works, illness functions as the force of inertia that propels temporary migration and the protagonists’ intensely introspective experiences. Together, the texts afford a closer look at the relationship between disease, migration, and familial reconnection.

Before they could propel women toward the criminal justice system, brokers had to contend with the fact that most women wanted to “run a family.” Before and during the actual work of mediation, brokers thus had to convince women to reorient their preferences. Chapter 5 shows how brokers encouraged women to approach the law for assistance. To do so, brokers provided concrete services and rewards: therapy, associational membership, job training programs, medical assistance, financial support. These psychological, social, and material incentives lowered both the perceived and the actual costs of legal cases for individual women while raising the potential benefits.

In Barra De Cazones, Veracruz, we ordered Modelos at an empty beach­front restaurant, La Palapa de Kime, on a muggy July afternoon. A handful of vacationers were scattered on the expansive, pebbled, brown sand beach. This was not the tropical paradise of Cabo San Lucas brochures—with expensive hotels and fine white sands—but the scarcity of tourists in this beautiful and serene Gulf Coast village was puzzling at first glance. The roads into town are good—pleasant, twisting runs through a remote and picturesque rainforest, in fact—and a couple of medium-sized cities and an airport are within an hours’ drive. We later learned that the electricity in town was sporadic and that the hotel accommodations were expensive but shoddy. And along the downtown strip, half-constructed buildings seemed frozen in their incompleteness, as if they were as ambivalent about the future as the inhabitants were. Roofless, these cinderblock buildings stood mute and abandoned alongside the central beachfront road, rusting rebar jutting out of the tops of their gray walls. In front of them, stacks of bricks lay idly on the sidewalk. This quiet fishing and farming village of a few thousand would like to reinvent itself as a tourist destination. Government efforts to create fishing cooperatives and plants for processing and freezing fish expanded Mexico’s annual catch in the 1970s and 1980s, but today Mexico’s coasts are dominated by U.S., Canadian, and Japanese boats, which catch ten times what Mexican boats do. Small-scale fishermen in places like Barra de Cazones fetch low prices for their fish, and high fuel prices take a sizable chunk of their meager earnings. With fishermen struggling, little investment in infrastructure, high interest rates, and few jobs, this lonely town’s main business, like that of the nearby villages of Volador and Agua Dulce, is out-migration. Archimedes, a proud and boisterous local entrepreneur, was frying several freshly caught fish in a wide skillet and extolling their virtues in a theatrical baritone.