Category Archives: Global Health

The wikipedia pithy definition is: the health of populations in a global context. https://en.wikipedia.org/wiki/Global_health

The Hanging Garden of Human Rights

Human rights haven’t failed because they’re irrelevant. They’ve failed because they’re a hanging garden—detached from moral roots, stretched by competing claims, and hollowed out by politics. It’s time to reclaim the foundation.

In the late 1990s and early 2000s, health and human rights was emerging. But the field carried intellectual divisions. On one side were the public health practitioners—many without legal training—who used the language of “rights” as a cry for decency. Rights, for them, became a sharper way of saying “ought” or “should”—signalling fairness and ethical urgency.

To the lawyers, this was infuriating. When they spoke of rights, they weren’t talking about moral gestures. They were talking about the law—about using legal instruments to empower action. What do treaties require of duty bearers? How do we hold them to account? General Comment 14 wasn’t a metaphor. It was a legal tool—an authoritative interpretation of the right to health under international law.

While the lawyers stayed with “human rights,” others drifted towards a more explicit discussion of equity, fairness, and (natural) justice. The split revealed a foundational problem. Human rights—the narrower legal and procedural endeavour—had become crucially detached from the ethical instincts that once animated the field.

The narrowing of human rights to law provided rigour, but lost moral reach. And as states learned to ignore legal obligations with impunity, what remained was often hollow. Public health had a moral language without teeth. Law had a legal language with contradictions and a weak ethical foundation.

Today, the international human rights framework is fraying—and in danger of complete collapse. It’s not a failure of aspiration. It’s a failure of structure.

We appeal to fairness, but we disagree on what fairness means. We invoke rights, but the legal instruments offer an incoherent and contradictory account of what grounds them. And when rights collide—speech versus protection, work versus life—we have no principled way to resolve the conflict.

Too often, the international human rights framework is treated as if it’s free-floating. The rights are asserted without grounding, and negotiated without foundation. We’ve built a symbolic garden of human dignity, but it hangs untethered—detached from root and soil.

What we need, I contend, is a moral structure beneath the legal scaffolding. Something that explains not just what rights exist, but why they matter—even when they’re inconvenient, unpopular, or costly.

A Different Kind of Foundation

The traditional approach to grounding human rights is to seek a foundation in reason, drawing on various traditions of moral philosophy. Yet each of these traditions—necessarily, though often implicitly—relies on a set of foundational assumptions that themselves demand justification. For example, John Rawls, working within the liberal contractarian tradition, assumes that morality can be derived from radical impartiality (the “veil of ignorance”). John Stuart Mill and Jeremy Bentham, as utilitarians, treat utility—happiness—as the basis of moral judgment. Thomas Aquinas, the Catholic theologian rooted in natural law, posits God not merely as a theological claim but as a rational necessity. Immanuel Kant, the deontologist and perhaps the most rigorously reason-driven of all, grounds morality in the capacity for rational self-governance—the idea that to be moral is to act only on principles one could will as universal law.

Unfortunately, reasoning our way to good behaviour does not seem to have worked.

An Axiomatic Approach

An alternative approach is to work backwards. Rather than deducing rights from reason, we ask: what must be true for rights to make sense at all?

Three axioms emerge:

Inherent Dignity

Every human being possesses inherent dignity. It’s not something to be earned, granted, or achieved—it’s a moral condition intrinsic to personhood. Dignity doesn’t fluctuate with ability, social contribution, or behaviour. It’s not comparative. It doesn’t admit degrees. It is equal and inviolable.

Individual Welfare

Dignity, while inviolable, is not self-executing. The social and legal order must promote the material, psychological, and social welfare of individuals—so they can live, develop, and participate meaningfully. Without these conditions, dignity is betrayed in practice, even if affirmed in theory.

Constraint on Expendability

No one is expendable. Lives cannot be sacrificed for the convenience or benefit of others—except under conditions of compelling and justified moral necessity, subject to strict and transparent constraint. Where institutions permit suffering for efficiency, or render individuals invisible in pursuit of “greater goods,” moral collapse has already occurred.

These aren’t ideals. They are constraints. They don’t define utopia. They define a moral floor beneath which no system can fall and still claim legitimacy.

Axioms to Rights and Duties

From these axioms, rights and duties follow:

From dignity comes the right to recognition, and the duty to respect others as full moral equals.
From welfare comes the right to the conditions for flourishing, and a duty to assist when the need is real and the cost is bearable.
From non-expendability comes the right not to be sacrificed, and a duty of restraint—to avoid complicity in systems that treat people as disposable.

These are not grounded in legal agreement. They are grounded in the foundational, moral necessity.

Once one begins to play with this axiomatic approach, what fast becomes clear is that the state, as a moral agent, has been miscast in international law. The state is not a de facto rights-holder, nor is it a source for the rights of others. The state is a duty bearer—nothing more.

The state exists to protect dignity, promote welfare, and prevent expendability. When it fails to do this—systematically, persistently—its legitimacy erodes. Its existence is not self-justifying; i.e., the purpose fo the state is not to perpetuate its own existence. Its existence is contingent.

This flows from the axioms, and reframes the conversation: human beings do not have moral standing because the state recognises them. The state has standing only to the extent that it honours the people within its reach. This is not anti-state. But it is deeply sceptical of the idea that the state’s authority is morally primary. It isn’t. People are.

When Systems Fail

The axiomatic approach is pluralistic, but it is not permissive. Some systems are structurally incompatible with these axioms. For example, autocracies treat rights as contingent on loyalty or usefulness. Dissent is punished not because it is wrong, but because it defies power. Theocracies, in contrast, base human worth on belief and compliance to doctine. The person becomes secondary to divine law—as interpreted, of course, by the state. In both autocratic and theocratic systems, rights are conditional. Recognition is revocable. Worth is earned.

The axioms say otherwise. Dignity is inherent. Welfare is required. No one may be discarded.

It would be wrong to claim that the axioms are an expression of “Western values.” The expression of these kinds of ideas can be found across tradition in Asia, Africa, and the pre-colonial America. They are put forth as minimum moral thresholds. The test isn’t, thus, one of cultural conformity to some putative “Western” ideal. The test is whether the system respects the moral worth of the people within it.

Against Relativism. And Democracy.

Some people will simply not agree with the axioms. They will argue that certain groups—racial, ethnic, religious—are less than, sub-human. That outsiders are un-deserving. That dissenters are worthless. Life is to be instrumentalised for some other end.

Relativism, when pushed far enough, accommodates this. It permits anything, so long as it is “culturally accepted.”

The axioms say: no. Some practices are beyond justification.

Nor do the axioms necessarily support democracy. Majority rule is not a moral guarantee. A vote to discard a minority is still a failure. Democratic decisions must be constrained by moral principles.

Power alone is not a justification, whether the source of that power is autocratic, theocratic, or democratic. Justification is determined by what power does. Too often, might is blight.

Holding the Line

The axioms emerged from a simple realisation. Many communities, political parties, and even nations now openly argue that the value of other people’s lives lies only in how useful they are to the ambitions of those with power. The human rights framework is under siege—not just from external enemies, but from those who claim to defend it. You can see this everyday in the statements and actions of leaders (and wanna-be leaders) around the world. Western and Eastern Europe, the Middle East, Central, South and East Asia, Oceania and the Americas—everywhere leaders seek to treat some group as “other”. “Those people”—outsiders, the un-deserving—are no longer means to allowed to be the means to their own ends, they are the means to ours.

States invoke rights while violating them. Institutions look stable but are morally hollow.

The axioms of dignity, welfare, and non-expendability do not resolve every conflict. But they clarify the ground. They give us a framework to test law, policy, ideology—and to know when a system has failed, even if it looks orderly.

You can read the full account, with examples and theoretical detail, in the preprint on SocArXiv:

But the core is simple:

People matter. Their lives must be livable. And they cannot be discarded.

I am shocked these ideas are up for debate.

This blog was first published on 24 May 2025 and further edited on 7 June 2025

The Foreign Gaze: A Review

Seye Abimbola’s book, The Foreign Gaze, is a thoughtful and often elegantly written account of how power distorts knowledge production in global health. Drawing on personal experience and philosophical insight, Abimbola introduces the concept of “the foreign gaze” to describe the way researchers, particularly from low- and middle-income countries (LMICs), shape their work for external audiences—northern donors, editors, reviewers, and institutions. The result, he argues, is a system where knowledge is produced not for the people it is intended to serve, but for those who control its global circulation and validation.

The strength of the book lies in its clear moral purpose. Abimbola calls for greater attention to “pose” (the standpoint of the knower) and “gaze” (the intended audience), and argues for an ethic of epistemic justice—where local actors are not just included in global conversations but are recognised as authoritative producers and users of knowledge in their own right. He speaks with conviction about the daily indignities of exclusion and marginalisation, and the ways in which academic global health often fails those working at the front lines of health systems.

And yet, for all its rhetorical clarity and moral force, The Foreign Gaze is ultimately an unbalanced critique. It targets external systems of authority—foreign reviewers, northern journals, donor agendas—without seriously interrogating the internal dynamics of epistemic dependence within LMICs themselves. In doing so, it offers a partial, and sometimes evasive, account of the problem it sets out to name.

First, the book is morally lopsided. Abimbola presents the Global South as the passive object of northern scrutiny, not fully acknowledging how deeply southern actors participate in, benefit from, and scaffold the system he critiques. Nor does he describe the effort that Global South actors will go to, to be seen by the Global North. Ministries of health design policies to satisfy donor templates. Researchers tailor proposals to align with northern funding calls. Academic careers are built on publishing in northern journals and securing foreign recognition. These are not the actions of helpless victims; they are rational and strategic choices made within unequal systems. Yet Abimbola offers little analysis of this internal complicity and treats the relationship as Manichean: colonial = bad, indigenous = good.

This lopsidedness extends to his treatment of knowledge. At key moments, he blurs the line between affirming the dignity of knowers and valourising the truth of what they claim to know. He rightly insists that people must not be dismissed because of their institutional distance from power—but he often slides into assuming that local practices are not only morally meaningful but epistemically equivalent to biomedical science. This argument is especially evident in his discussion of Nigerian group antenatal care, which he treats as if it should be shielded from empirical evaluation, even while dismissing external attempts to rigorously assess it. The suggestion is that foreign testing is not just misplaced but offensive.

Yet this defence reveals a more profound contradiction. The Foreign Gaze claims to champion epistemic justice but curates who counts as a knower. Abimbola elevates midwives, grassroots health workers, and insider academics, but gives little attention to the knowers within communities whose influence may be coercive, regressive, or misinformed. The dignity of knowers, in his account, is reserved for those whose knowledge can be rendered morally resonant. In this way, the book replicates the very asymmetries it aims to dismantle: it replaces epistemic exclusion with selective inclusion, rather than with principled universality.

Though Abimbola does not argue for relativism outright, his privileging of proximity lacks an accompanying framework for testing or contesting local knowledge. In practice, this leaves him affirming certain local claims without clear criteria, especially when those claims conflict or reproduce harm. By challenging foreign authority without articulating how legitimacy should be assessed within local contexts, he risks substituting one opaque hierarchy for another. The absence of a mechanism for epistemic accountability within the ‘proximate’ space undermines the critical edge of his argument.

Second, the book is epistemically incomplete. It assumes that valuable local knowledge lies waiting to be recognised if only the foreign gaze would look away. While Abimbola acknowledges that local experts often tailor their work for foreign audiences, he avoids more profound questions about how this orientation emerged and why it endures. He does not examine how colonial and missionary legacies have shaped the epistemic cultures of southern institutions, or why local scholars rarely seek to theorise indigenous practices on their own terms. For instance, he praises group antenatal care in Nigeria as a locally grounded example, but never considers how inherited pedagogies already structure such practices. The deeper question is, why has so much southern knowledge production become mimicry rather than innovation?—remains largely unexplored.

This omission is particularly striking in light of historical examples like the suppression of variolation in colonial India. Indigenous practitioners had developed a functional method of smallpox inoculation, yet this knowledge was not allowed to evolve because colonial authorities replaced it with vaccination. The British enforced an epistemic closure from the outside, but the long-term effect was an internalised deference to another’s science. Abimbola touches none of this. He writes as if the gaze is the primary agent, and the south merely its object, ignoring the centuries of adaptation, aspiration, and abandonment that have shaped southern scientific cultures from within.

Finally, the book is strategically ineffective. It underestimates how profound a shift would be required to build independent knowledge systems in the Global South–to shed centuries of epistemic entanglement with the North. To reorient from the foreign gaze is not a matter of redirecting papers to different journals or holding conferences in other cities. It would require building entire epistemic infrastructures: funding mechanisms, review systems, training institutions, and incentive structures capable of rewarding intellectual independence rather than recognition. Abimbola offers no roadmap for this transformation. Nor does he seriously consider whether the current generation of southern institutions—so deeply entangled with northern agendas—could or would lead such a project. In this sense, the book gestures toward autonomy but remains captive to the very structures it critiques.

The core of the problem is this: The Foreign Gaze critiques the act of being watched, but says little about the desire to be seen. It offers a sharp analysis of how knowledge is distorted by foreign audiences, but not of why southern actors so often turn toward those audiences in the first place. Without that second half, the argument remains morally insufficient and structurally incomplete. Finally, it calls for justice, but offers no confrontation with the habits of thought, aspiration, and institutional design that prevent it.

In privileging proximity and local accountability, Abimbola gestures toward a world where “global health” no longer holds together as a coherent epistemic or institutional project, but he stops short of naming this dissolution or reckoning with its consequences.

The Foreign Gaze opens a critical conversation but does not complete it. If epistemic justice is to mean more than moral appeal, it must reckon with both the gaze from without and the longing to be seen from within. Until then, the project risks becoming, in the end, just another performance in the theatre of Northern validation.

Seye Abimbola (2025). The Foreign Gaze: Essays on Global Health. OpenEdition Books: Marseille.

Parsing the NIH Reform Debate

I was recently alerted to Martin Kulldorff’s Blueprint for NIH Reform — a document that’s stirred some intense reactions among my colleagues. A few view it as a needed critique of systemic inefficiencies. Most regard it as an ideological Trojan horse—an attack on science dressed as reform. So where does the truth lie?

The short answer is: it’s complicated—and the messenger matters.

Kulldorff, once a Harvard professor and biostatistician, became a polarising figure during the COVID-19 pandemic for promoting ideas widely dismissed by the mainstream scientific community, including opposition to lockdowns, masking, and even some aspects of vaccination policy. He was also a co-author of the controversial Great Barrington Declaration, which called for herd immunity through natural infection — a strategy many experts considered unscientific and dangerous at the time.

This background understandably colors how his recent proposals are received.

But here’s the nuance: the Blueprint itself raises a number of ideas that aren’t inherently fringe. Calls for reforming NIH grant structures, enhancing academic freedom, incentivising open science, and streamlining peer review are echoed by many researchers across disciplines — including those with no ties to politicised public health debates. Frustrations with bureaucratic inefficiencies and perverse incentives in scientific funding are real and shared.

Where it becomes tricky is in the framing. Kulldorff doesn’t just argue for reform — he implies that current structures are suppressing truth, and that controversial views (like his own during the pandemic) have been silenced not because they lack merit, but because of groupthink or institutional bias. That framing, for many, crosses the line from constructive critique into undermining the scientific process itself.

There’s also a risk that pushing for more “openness” in what research gets funded — while laudable in theory — could result in resources being diverted to low-evidence, high-noise pursuits. Or, as one colleague aptly put it, “sending the ferret down an empty warren.” Science thrives on curiosity, but it also requires discipline and evidence-based filters.

Venue choice also matters. If this proposal were intended as a serious intervention into science policy, it might have been published in a mainstream medical or policy journal where it could be openly debated across the full spectrum of scientific opinion. Instead, it was published in the Journal of the Academy of Public Health — a platform co-founded and edited by Kulldorff himself, with close ties to politically conservative and contrarian public health figures. That choice raises questions about whether the article is seeking reform through consensus, or carving out space for alternative narratives that have struggled to find support in mainstream science.

So how should we engage with this?

Acknowledge the valid points: There is room — and need — for reform in how science is funded, reviewed, and communicated.
Be vigilant about context: Not all calls for reform are neutral. Motivations and affiliations matter, especially when public trust is on the line.
Defend the integrity of science: We can advocate for better systems without abandoning the core principles of evidence, rigor, and accountability — including fair peer review and a balance of risk and reward.

In the end, this is not a binary question of “pro-science” vs “anti-science.” It’s about how science evolves, who gets to shape that evolution, and what values we prioritise along the way — openness, yes, but always in service of evidence and public good.

This is an independent submission, edited by D.D. Reidpath.

The Great Trade Experiment

Last month I wrote about The Great Foreign Aid Experiment of the Trump administration. Foreign aid has not been without its critics because it is inefficient, promotes corruption, or is a part of an insidious program of neo-colonialism. The decision, however, by the US Government to put foreign aid “through the wood chipper” sets up a natural experiment to test whether aid save lives—more precisely, whether the sudden removal of aid ends lives. Most people in global health believe that it will result in significant suffering, although some see a silver lining: deaths among the poor and vulnerable will mark the emergence of independent health systems in low-income countries that are more resilient and finally free of external interference.

Not content with one natural experiment at the expense of the global poor, on the 2^nd of April 2025, Donald Trump announced the imposition of the highest rate of tariffs on US imports in almost 100 years. In effect, the government is dismantling the free-trade mechanism that has been operating since the mid-1990s, and adopting a more isolationist market posture. Under this new theory of trade, wealth is not created, it is finite and accrued by one country to dominate another.

The evidence has been pretty clear about the effects of poverty on health. Poor people are more likely to die than rich ones. Infant, child, and maternal mortality rates are significantly higher among the poor. Preventable and treatable diseases such as HIV, tuberculosis, and malaria also disproportionately infect and kill the poor. These poverty effects occur both within and between countries. Furthermore, they are not just biological outcomes—they are deeply social, economic, and political in nature. The conditions of poverty limit access to healthcare, nutrition, education, and safe living environments.

Over the last 75 years, in parallel with increasing life expectancy across the globe, wealth has also increased. The proportion of people living in extreme poverty today is much lower than it was 50, 20, or even 10 years ago. In fact, historically the sharpest global decline in extreme poverty occurred between 1995 and 2019—2020 was, of course the COVID pandemic, which reversed a wide rage of health and economic indicators.

Bill Clinton assumed the presidency of the United States in January 1993. He was supportive of free trade and the Uruguay Round of of the General Agreement on Tariffs and Trade (GATT), which was completed in 1994. The successful conclusion of GATT led to the creation of the World Trade Organization (WTO) in January 1995.

Following the liberalisation of trade, global extreme poverty rates fell from 36% to 10% between 1995 and 2018. In South and South-East Asia the extreme poverty rates fell from 41% to 10%. In Sub-Saharan Africa, the extreme poverty rates fell substantially, but without the same speed or depth as elsewhere: 60% to 37%. The gains of trade liberalisation were also more advantageous to some markets than others, and it particularly benefited countries with cheap manufacturing capacity such as Bangladesh and Cambodia.

The sudden US reversal on tariffs will be punishing for those poor countries that have developed a manufacturing sector—particularly in shoes and garments—to provide cheap, volume goods based on low labour costs. Of course, the goods in the US need not be cheap, because there is considerable profit in branding.

If exports drop significantly, factories will want to cut staff numbers swiftly to retain their commercial viability. Poor households, particularly those reliant on a single income manufacturing jobs, will likely be thrown backwards into extreme poverty. The global economic gains of the last 30 years could begin to reverse. A major drop in exports will have an immediate impact on the factories’ labour force but there will be flow on effects to the entire economy of poor countries. In Bangladesh, for example, garment manufacturing is the single biggest source of export revenue, and reductions here will mean reductions in national tax revenue which supports health, education and welfare services.

In other LMICs that are less reliant on a global export market, shifts in tariffs will have a concomitantly smaller impact. Thus, the two natural experiments will intersect. The impact of foreign aid on health and the impact of foreign trade on health will play out with interacting effects.

Needless to say, none of this was ever framed as an experiment. Cutting aid and raising tariffs was all to “Make America Great Again”. It is a cruel, indifferent approach to trade and foreign policy. There will be no one in the Situation Room plotting a Kaplan-Meier survival curve. No policymaker will announce that the hypothesis has been confirmed/rejected: that wealth, when withdrawn or walled off, leaves people dead. Nonetheless, the data will tell its own story.

And when it does, it won’t speak in dollars or trade deficits. It will speak in the numbers of anaemic mothers, closed clinics, empty pharmacies, and missed meals. It will speak in children pulled from school to help at home. It will speak in lives shortened not by biology, but by policy

The Great Trade Experiment, like the Great Aid Experiment, won’t just test theories in global health and economics. It will test people—millions of them. And the results, while statistically significant, will not be ethically neutral. Some experiments happen by accident. Others, by design.

This one was designed—by the President of the United States.