Category Archives: Equity

Related to the fairness of distribution of goods, opportunities, and processes.

An image of two children in Belgian Congo. One is seated and one is standing. Both children are missing their right hands.

Aid cruelty is not an opportunity

I have followed with genuine interest the responses of some sub-Saharan African (SSA) writers to the collapse of foreign aid in 2025. Whether they reside in SSA or enjoy a diasporic life in the Global North, they have argued that the loss may be an opportunity gifted to the Global South. While millions will die, SSA will at last be able to throw off the multi-billion dollar shackles to which it was so unwillingly chained. How awful to have been placed in the position of choosing between the “n”-word—“no”—and the “y”-word—“Yes!”—when offered money.

The tenor of the writing suggests that in making the offer of aid, countries in the Global South were stripped of agency. They could only rediscover agency when they were stripped of the money. The evil aid system by which the Global North klept [sic] them enthralled has at last been dismantled. The opportunity, long denied, has finally emerged to build health and development systems that “work for Africa”.

You will, I hope, forgive me if I do not join that cheer squad or Greek chorus.

In left-wing politics, there is an aphorism that it is better to suffer exploitation than starvation. To cheer unemployment for the liberating opportunities it provides from the excesses of exploitative capital is as short-sighted as it is stupid. That does not mean exploitation is acceptable. It is not. It must be resisted and fought. But starvation is not the solution.

If foreign aid was a shackle, its sudden removal should be freeing. But stripping away the existing system does not automatically lead to something better. Stretched governments cannot replace the wreckage of collapsed health programs overnight. What may look like liberation on paper is abandonment. A just transition requires negotiation and genuine collaboration. It requires time.

If the goal was to end aid, donor countries could have managed future aid through a phased reduction. The process could include such things as a shift to loans on beneficial terms combined with early debt management and relief. The development of capacity, systems, and infrastructure would need to be a part of it.

When you reach into the water to remove a life-jacket from a drowning man, you have not provided him with an opportunity to learn to swim, nor have you (passively) “let him die”. You have killed him. He may bob above the waves for a few minutes, even an hour. You may helpfully scan the horizon for a bit of passing flotsam for him to cling to. But when exhaustion finally overwhelms him, and he slips beneath the surface, you are a murderer.

When, with the snap of the fingers, a country closes HIV antiretroviral programs—leaving the drugs to rot and expire in warehouses and shop lots—it has not (passively) let people living with HIV/AIDS die. The donor country condemned them to death and waited.

The personal relationship with the individual drowning and the anonymous one with the hundreds of thousands of people on foreign-aid-funded antiretroviral does not change the moral calculus of the death, and it does not mitigate the callousness and wanton cruelty of the murder.

Aid programs are not light switches that donor countries can (or should) turn off on a whim. Cutting funding overnight destroys systems that took decades to build, leaving chaos in their place. The systems may not have been perfect; they may have needed greater local ownership in the design; they may have supported corruption. However, if the goal is genuine self-reliance, the responsible course is a phased, predictable transition that allows for capacity-building, infrastructure development, and systems design and refinement.

Millions have been condemned to death, others to lives of increased hardship and misery. If donor nations refuse to acknowledge their historical responsibility, then at the very least, they must be held accountable for the consequences of their actions today.

The world’s wealthiest countries’ substantial and immediate reduction in foreign aid turns their backs on the international human rights, their international obligations to support the SDG, and the obligation to leave no one behind. The United States (U.S.) led the pack when they put USAID “through the wood chipper”, but others have followed.

“The UK, the Netherlands, and Belgium have announced the largest cuts in [overseas development assistance] ODA history, and the European Commission, France and Germany are expected to follow soon. These cuts are not just minor shifts, but cliffs: at least USD 60 billion by USA and GBP 6 billion by the UK, EUR 8 billion over four years (2025-2028) by the Netherlands, and a possible EUR 20 billion by Germany.”

What is the unifying historical theme of these donor countries? Empire. They did not build their wealth on ingenuity or fair trade alone. Conquest, forced labour, and resource theft was there. They racialised the right to development. The UK drained its colonies of raw materials while imposing economic structures that prioritised British interests over local development. Belgium’s rule over the Congo was so extractive and brutal that its legacy still echoes in governance failures and economic instability today. France has reluctantly and only recently relinquished control over its former colonies, where it maintained economic dominance through ‘Françafrique’ policies that benefited Paris over Dakar.

Slashing aid is not an opportunity. It is abandonment. Do not let them disguise it as anything else. Do not allow the wealthy nations to pat themselves on the back for their cruelty. It is an outrage, and it must be named as such.

The outrage does not erase the agency of recipient countries that agreed to destructive conditionalities attached to receiving aid. It does not forgive the naked corruption that sometimes occurs. It does not excuse the capacity of poor countries to exploit their even poorer neighbours, nor the exploitation of social stratification within their societies.

But none of these realities justify the wholesale destruction of life-saving programs without a plan, without accountability, and without justice. Nations that built their wealth through exploitation cannot now walk away and abandon vulnerable countries, whether they were directly plundered by them or by others. If they do not uphold their obligations, civil society, recipient governments, and international institutions should demand an ethical transition rather than an overnight abandonment that costs millions of lives. Anything less is complicity in death.

 

American politics symbolized by the closure of USAID, reflecting a shift in international relations and policy.

The Great Foreign Aid Experiment

Foreign aid is bad. It’s bureaucratic, top-down, inefficient, promotes corruption and dependence, and does not get to where it’s needed. That has been the common refrain. A recent, novel addition to those complaints is that aid does not return sufficient economic value to the donor. Now, thanks to the US government’s dramatic shift in foreign aid, we have a natural experiment to test the hypothesis: no more counterfactual models, economic pontification, and ivory tower theorising. We’re going to get the data!

Inflation-adjusted global aid transfers have increased steadily from US$35 Billion in 1960 to $190 Billion in 2021. In that time, alongside broader economic and technological advancements, we have seen dramatic global improvements in infant and child mortality, maternal mortality, life expectancy, and extreme poverty rates.

From 1961 to 2024, the general, global approach to foreign aid was shaped by the Kennedy administration’s passage of the Foreign Assistance Act (1961). Kennedy’s approach marked a shift from ad hoc post-WWII aid programs to a structured, long-term commitment to development. Its purpose was “[t]o promote the foreign policy, security, and general welfare of the United States by assisting peoples of the world in their efforts toward economic development and internal and external security, and for other purposes.” The bill reorganised US aid and created the United States Agency for International Development (USAID). Since then, global approaches to foreign aid have evolved, especially after the Cold War, incorporating humanitarian assistance, economic development, and global health initiatives.

While approaches to foreign aid have evolved since the early 1960s, there have been persistent calls for radically restructuring aid. The general nature of the complaint has changed little. Aid is bureaucratic, top-down, inefficient, promotes corruption, and does not get to where it is needed: Bauer (Dissent on Development, 1976), Hancock (Lords of Poverty, 1989), Maren (The Road to Hell, 1997), Sogge (Give and Take, 2002), Easterly (White Man’s Burden, 2006), Moyo (Dead Aid, 2009), and Deaton (The Great Escape, 2014).

Thanks to the new Trump presidency, we will have an unexpected and dramatic test of the value of aid. He gave us a quasi-experimental (natural experiment) test. One of the many Executive Orders he signed on inauguration day was “Reevaluating and Realigning United States Foreign Aid”. He determined that:

“The United States foreign aid industry and bureaucracy are not aligned with American interests and in many cases antithetical to American values. They serve to destabilise world peace by promoting ideas in foreign countries that are directly inverse to harmonious and stable relations internal to and among countries.”

We can dismiss any notion of equipoise, the idea that there is some real or dramatic doubt about the direction of effect. The great bottom line (spoiler alert!): people will suffer and die.

As the modern masters of sprawling cruelty, the US Government set about withdrawing hundreds of millions of dollars of aid. By the 28th of March (one month and one-week post-inauguration), the impact of the terminated funding is already affecting direct and indirect services to millions of people in low- and middle-income countries. The effects are so interconnected and global that the only real question is not “Will it be bad?” but “How bad will it be”?

Infectious diseases, big (HIV/AIDS, TB, Malaria) and small (Onchocerciasis, Filariasis,…) will lose prevention, treatment and management funding. Maternal and child health services, including sexual and reproductive services, have been gutted. Multilater, UN agencies have lost funding, as have international NGOs, national NGOs, and small civil society organisations.

But perhaps we should look at the cup half full and celebrate. The grand experiment is finally here. For decades, sceptics have argued that aid is ineffective, stifles self-sufficiency, entrenches corruption, and moves the needle of human progress insufficiently far. Now, at last, we will see an aid-free world through a lens of unvarnished reality. No more speculation, no more hypothetical debates. The world’s poorest countries will become their own control group.

The beauty of the US experiment is its scope. Unlike carefully designed studies of aid effectiveness from behavioural economics labs—where researchers squabble over metrics, counterfactuals, and model assumptions—this will be a real-world, systemic demonstration.

And of course, when the numbers start rolling in—the maternal deaths, the malnutrition rates, the outbreaks of diseases once thought to be on the retreat—there will be no shortage of explanations.

There is nothing surgical about the US Government cuts to aid, nor are they simply recalibration. They have declared ideological war against the world’s most vulnerable, and we will count the consequences in human lives.

If the sceptics were right, we should see a golden age of self-reliance and local ingenuity, unshackled from the oppressive hand of foreign assistance. If they were wrong—well, the numbers will tell their own story.

Will anyone care to listen?

Trump v. Thucydides

Today is one month and one day(!) since the inauguration of Donald J. Trump for his second term as President of the United States (US).

In that time, he delighted in claiming dominion over Greenland, the Panama Canal, and the Palestinian territory of Gaza. He has humiliated treaty allies, cuddled up to recently acknowledged enemies of the US and her (former?) allies, and threatened trade wars against friends and foes alike. He has unleashed Elon Musk on the federal bureaucracy, effectively closing congressionally legislated departments. He has withdrawn life-saving medicines from millions of people around the world and declared ethnic cleansing a US policy.

Donald Trump is stomping on the norms of US democracy. He has the constitutional pardon power in one hand and US Supreme Court protection from prosecution in the other. He is basking in the absolute power of a monarch and turning the global, rules-based order (of which the US was the principal architect) into a plaything.

Louis XIV of France (reign: 1643–1715)—the “Sun King”—owned canons bearing the inscription Ultima Ratio Regum (“The Last Argument of Kings”). It was a pun-filled reference to the idea that the ultimate recourse of a ruler is violence. He was reminding friends, enemies, and subjugates that when his laws (canon) failed, his capacity for violence (cannon) would triumph.

Political Realists see Louis’s cannons as reifying the political idea that “might is right” (MiR). That is, power and not morality ultimately determines outcomes. As they watch Donald Trump tear down democracy and attack the global rules-based order, they make coded references to the ancient Greek historian Thucydides—hero of Realpolitik and the guy who wrote the History of the Peloponnesian War. It is to him the phrase “might is right” is attributed, based on a brief passage known as the Melian Dialogue.

The dialogue is a brutal exchange between envoys from Athens and the leaders of the small island of Melos—the same Melos famous for the statue of the Greek goddess Venus (“di Milo”). The Athenians explained that neutral Melos would have to side with Athens in their war against Sparta or be destroyed by the larger army of Athens. They did not prevaricate of sugar-coat the delivery of their message. And it is this exchange that has been reduced to MiR.

There are, however, significant problems with this position. First and foremost, Thucydides never actually wrote, “might is right”—not even close—and the suggestion that he did becomes a self-serving distortion used to justify ruthless power politics. Thucydides actually recorded the Athenian envoys saying, “The strong do what they can, and the weak suffer what they must.”

To be pedantic—necessarily so—he actually wrote, “οἱ μὲν δυνάμενοι πράσσουσιν, οἱ δὲ ἀσθενεῖς ξυγχωροῦσιν.”

The nuance in translation is crucial. The standard English rendering, “The strong do what they can…” relies on the modal verb “can,” which in English (and in French with pouvoir) suggests freedom of will—the idea that those with power act as they choose. But ancient Greek had no direct equivalent to modal auxiliaries like can or must.

The critical verb here is δυνάμενοι, a participle of δύναμαι (to be able). Rather than conveying a sense of willfulness, it implies something closer to necessity—that the strong act as circumstance dictates in accordance with their power, just as the weak yield because they also have no choice. This translation reflects the broader Thucydidean theme that power operates under the constraints of ἀνάγκη (necessity).

It is tragedy rather than psychopathy that is the binding relationship between Athens and Melos. Melos, for all its appeals to justice, is doomed. It refuses to bow to Athenian demands and is annihilated. However, the fate of Athens itself is no less bleak. The logic that drives The Athenians to subjugate Melos ultimately consumes them as well, leading to their downfall in the Sicilian Expedition and, eventually, their total defeat in the war. The same compulsion that led them to destroy Melos leads to their destruction.

Thus, when “might is right” is used too quickly to explain the actions of a leader, there is a danger that political scientists give moral cover to the immoral. They fall back on relativistic notions that the whim of the caveman with the bigger club determines societal norms.

Donald Trump is not acting out of tragic necessity. He does not wield power because it has to be wielded. It appears that he does what he does because he is an aggrieved psychopath who revels in the opportunity to put metaphorical kittens in a sack and drown them.  

Thucydides would not recognise Donald Trump as any of the actors in the Melian Dialogue.

There was no necessity to put millions in the path of death by withdrawing life-saving treatment. There was no necessity to propose the ethnic cleansing of Gaza. There was no necessity to threaten to take a NATO ally’s territory. There was no necessity to begin to tear down the multilateral system.

A socially and fiscally conservative leader might share many policy objectives with Donald Trump and his followers. There is no necessity, however, to reach those objectives by choosing the most cruel and destructive path possible.

Donald Trump is not a brilliant or tragically compelled leader; he is a psychopath.

When the U.S. ‘leans out’ of Global Health

The most powerful country on the planet has just ‘leaned out’ of global health. Will the Global South take the opportunity to ‘lean in’?

Yesterday, at a lunchtime talk at the World Health Organization (WHO) Headquarters in Geneva, Dr Madhukar (Madhu) Pai spoke on “Shifting Power in Global Health”. His presentation drew on ideas he had recently published (with Bandara and Kyobutungi) in the Lancet. The talk picked up on a consistent theme—the entrenched power of the Global North in global health—often white and male, but not necessarily.

One of the ideas Pai promoted was that of “allyship”. Rather than leading in global health fora, he suggested that Global North researchers, practitioners, and policymakers need to become allies of Global South counterparts. The role is to encourage and support those from the Global South in leadership.

In the online chat, one attendee wrote,

“I also want to challenge the notion of allyship. I think what we need is people with power and privilege to ‘lean out’ and make space at the table for folks with less power to exercise their leadership.

In other words, worry less about being an ally. Get out of the way, and people in the Global South will have the space to step in.

The comment was particularly pertinent given the stated intention of the United States (US) to withdraw from WHO. WHO is the global body with the most sweeping engagement in global health and the US was about the ‘lean out’—a perfect natural experiment.

The Executive Order (EO)—“WITHDRAWING THE UNITED STATES FROM THE WORLD HEALTH ORGANIZATION”—was signed by Donald Trump on his inauguration, 20 January, 2025.

Trump tried to withdraw from WHO in 2020. He left it too late, and Joe Biden was able to rescind the order. Not this time! The new EO also pauses support for WHO immediately. Section 2d of the EO states, in part:

(d) The Secretary of State and the Director of the Office of Management and Budget shall take appropriate measures, with all practicable speed, to:

    (i) pause the future transfer of any United States Government funds, support, or resources to the WHO;

    (ii) recall and reassign United States Government personnel or contractors working in any capacity with the WHO;

The decision to withdraw is very unwise—a disservice not only to people in the US but to the global community. It jeopardises lives both domestically and internationally. However, if the goal is for those with power and privilege to make room at the table for others to lead, this structural shift could enable that. If the US withdrawal is unavoidable, the focus should be on leveraging it for the greatest possible positive impact.

It remains to be seen how aggressively the US government will enforce the immediate pause of “funds, support, or resources” (S.2(d)(i)). What is clear, however, is that funding will likely cease swiftly. There may be a brief trickle as any existing commitments are untangled, depending on whether the new administration feels compelled to honour agreements made by its predecessor. Regardless, the relationship with WHO is effectively ending. The same applies to the expertise of government employees and contractors (S.2(d)(ii)), which the US will also withdraw.

But what about the “support or resources” mentioned in S.2(d)(i)? The US withdrawal from WHO could also extend to the engagement of US universities and research institutions. This could include collaborative projects involving third parties where US institutions and WHO are partners. The extent of the impact will largely depend on how far the Trump administration is willing to go. Given its history, it could act aggressively to enforce the directive and interpret it permissively.

At its most extreme, the administration could target funding to US universities and research institutions, arguing that any expenditure providing even nebulous “support or resources” to WHO is a violation. US Universities could be endangered if the funds they have received require approvals from the State Department or the Office of Management and Budget. A single dollar of perceived “support” might jeopardise tens of millions in funding for these institutions. The mere threat of such action could intimidate university administrators, compelling them to redirect activities and disengage from collaborations involving WHO (even tangentially).

We have already seen billionaires and news organisations engage in “anticipatory obedience”. Why would we imagine that universities would be any less callow?

The danger here is two-fold. The first problem, as identified by Wiyeh and Mukumbang in their Lancet letter responding to Pai’s article, is the question of capacity. If the US expertise from researchers, practitioners, and policymakers vanishes, how much of the resulting gap can realistically be filled by the Global South? If stakeholders from the Global South oppose the current power structures of global health, they must ‘lean in’ as the US ‘leans out’. While they cannot fill the void entirely, they may be able to occupy some of the vacated seats at the table.

The second issue is the risk of alternate state capture. Any nation willing to fill the funding void left by the US withdrawal could justify claiming significant influence at the tables previously dominated by the US. WHO must engage in careful and strategic negotiation to prevent one hegemon’s “leaning out” from enabling another to capture its place. The true goal is to diversify representation, and there is little to celebrate in simply replacing one dominant voice with another—from whatever geography they originate.

There is no joy in the US withdrawal from WHO. Working together, however, WHO and countries in the Global South could use this unsought “opportunity” to address structural flaws in the power distribution of global health. Ideally, other significant Global North countries working in global health will support these initiatives—or at least get out of the way. Following Wiyeh’s and Mukumbang’s suggestions, building leadership and technical capacity, amplifying diverse voices from the Global South, and prioritising equitable partnerships will not only strengthen WHO’s ability to adapt but also create a more inclusive and resilient global health system in the face of this challenge.