Category Archives: Global Health

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

US Aid: Strategic Transactionalism

The US Government is showing all the compassion of a loan shark, where the Rubio Rule rules—”What’s in it for me?” Tragically, any international social capital the U.S. built over the past 80 years has been torched in a bonfire of pointless cruelty.

Yesterday, Politico published a draft document obtained from a government aide describing a revamped USAID. It is entirely about the U.S.—safer, stronger, more prosperous—with the benefits to others only arising en passant, if at all.

According to the document, international assistance will focus on investments that deliver “first-order benefits back home [in the U.S.]”. That is, there must be an immediate, directly attributable gain to the U.S. from it’s humanitarian “investment”. This is in marked contrast to the successful decades of soft power developed by the U.S. after World War II.

Global Health would sit in a new agency for International Humanitarian Assistance (IHA).

“By responding rapidly to natural disasters, preventing famines, containing disease outbreaks, and securing peace, IHA would demonstrate American values, prevent instability that could threaten our interests, distinguish ourselves from our geo-political adversaries (such as China), enhance U.S. leadership on the global stage, and increase safety at home.”

That sounds great! I wonder what those Amercian values are? They are not the values of compassion or empathy, nor the values established by the U.S. in the international human rights instrument. Those international values established by the U.S. are the ones that the Trump Administration has “put through the wood chipper”.

The values must be those of “strategic transactionalism”. This is my newly minted term that refers to the idea that no agreement with the U.S. can be trusted because it has shown itself to have no regard for such things. Agreements, contracts, and treaties exist only to the extent that the administration chooses to honour them. Here today, gone tomorrow.

What’s in it for me?

According to the document, “in all cases, countries would have to demonstrate high levels of “commitment” to be eligible for any U.S. assistance engagement”.

“High levels of ‘commitment’” is code in the world of crime bosses and authoritarian leaders for absolute subjugation. A country will do what it is told, when it is told—without question. Give up resources. Cede Territory. Treat some people as less worthy than others.

“Success would be measured by concrete metrics: lives saved, outbreaks of infectious diseases contained, pandemic prevented, famines averted, and measurable increases in in positive perception of the United States in emerging markets.”

The irony of this is that things like “lives saved” is exactly what was being measured before the conflagration. The new metric appears to be “measurable increases in positive perception of the United States in emerging markets”.

Rest assured, any positive perception of the U.S. is now only a form of “strategic transactionalism”. It is performative because money is still money, but anything else from the US risks bully, bluster, and betrayal.

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.

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?

The Purge

The Trump administration has started one of the most significant assaults on human knowledge in centuries. Well-collected, curated and communicated data are facts—an evidence base. When facts contradict a political narrative, they are dangerous. The US government has realised the danger and begun The Purge. The government will now establish new “facts” to replace old facts. Purge-and-replace is part of the process of state capture. Evidence represents dissent, and the government must crush dissent. Reality is altered.

Until a week ago, successive US governments had invested in a data, evidence-based policy enterprise with generous global access. It was a resource for the world that supported research and evidence-based decision-making. And, unless the information was classified or subject to privacy laws (e.g., HIPAA for health data), anyone could look at everything from labor and criminal justice statistics to environmental and health data.

Going, going … !

Starting late last week, government websites began to disappear; among them, the USAID website vanished without a trace. All the development evidence USAID published has disappeared. If you try to reach the website today (2 Feb, 2025), you will get a message from your internet provider informing you the site does not exist. Perhaps you have the wrong address…or maybe it was never really there. (Queue spooky music.)

Individual pages on government websites are also disappearing. The Centers for Disease Control and Prevention (CDC) webpage, for example, providing evidence-based contraceptive guidelines has vanished. A week ago, the guidelines helped people exercise their reproductive choice using the best available evidence. But facts are dangerous. The idea of personal autonomy in reproduction runs counter to the authoritarian narrative of the current US administration. CDC is being scrubbed clean.

Data are also disappearing. The Youth Risk Behavior Surveillance System (YRBSS) is a longitudinal survey of adolescent health risks coordinated by the CDC. If I search the CDC website for “YRBSS”, I get links. If I follow the links: “The page you’re looking for was not found”. This loss of data is a tragedy. A quick look at PubMed reveals the kind of research that has used YRBSS data: everything from adolescent mental health to smoking. Without those data, no one today could do the same kind of research that was done before. Trends in adolescent health are lost and we will not know about any emerging health risk factors. It is hard to know precisely why the YRBSS has disappeared. However, in keeping with the religiously conservative nature of the current US government, maybe it is adolescent sex that is too dangerous for people to know about.

The US government is not content with just removing facts. They also want CDC scientists to rewrite their research to adopt a single, approved, authoritarian view of the world. Their research must conform to the Trump government’s ideology. An approach which is oddly reminiscent of Stalin’s insistence that Soviet researchers adopt the dead-end genetic science of Trofim Lysenko.

The CDC has instructed its scientists to retract or pause the publication of any research manuscript being considered by any medical or scientific journal, not merely its own internal periodicals…. The move aims to ensure that no “forbidden terms” appear in the work. The policy includes manuscripts that are in the revision stages at a journal (but not officially accepted) and those already accepted for publication but not yet live.

It hasn’t happened yet, but I have to wonder what will happen when the US Government targets PubMed and PubMed Central—exceptional scientific resources provided free of charge to the world by the National Library of Medicine (NLM)? NLM could be directed to purge from the database all abstracted data on every journal article that contains ideas that do not support the government’s worldview: gender, transgender, climate change, vaccines, air pollution (from fossil fuels)…. Commercial providers could still abstract those articles, but the damage would be enormous.

The vaccine denier, Robert F. Kennedy, junior, is currently being confirmed as Secretary of Health. He believes the widely debunked, fraudulent claim that vaccines cause autism. What happens when he decides that the National Library of Medicine should selectively purge evidence debunking the vaccine-autism link? Will that mean vaccines cause autism in the US (a “US-fact”) but not in the rest of the world (a “fact-fact”)? Researchers in universities and institutions that can afford subscription services can avoid such excesses, but that will not be the case for many Global South researchers who rely on PubMed for their research, nor will it be the case for the general public, who also have free access to PubMed.

I have focused on health because it is the domain I know the best. There is, however, almost no factual resource of the US government that will be safe from the purge. Facts that endanger a Trump administration political narrative must not be allowed to exist.

The US government is a climate-denying administration that has again pulled out of the Paris Climate Accord. It has already targeted climate change research. Justice, labour, and population statistics that do not conform to the US government’s socially conservative, racist and xenophobic views about the world will also be in danger. Trade data that don’t support Trump’s political narrative of a “golden age” will need to be adjusted.

One of the great tragedies is that, now that the US government has shown itself to be institutionally disinterested in (or actively opposed to) facts, it has endangered the value of its entire evidence-based policy enterprise. If you visit a US government website in a year, will you trust the content? You shouldn’t. Instead, you should ask yourself what political interest influenced the information. Researchers, policymakers, journalists—everyone— will need to parse US government websites like they parse information from any other authoritarian regime. Sadly, research coming out of US universities will also require extra scrutiny. Where we trusted the voices before, now we would need to ask, has US government policy biased it, what is the nature of the bias, and can we manage the bias?

Sometimes, it will be easier to ignore US research altogether because verification carries a cost.

There are small glimmers of hope. Archive.org (the Wayback Machine) has historical snapshots of US government websites, including some data snapshots, such as the YRBSS. These snapshot are BTP (befor the purge). Unfortunately, the archive is not as easy to navigate as the World Wide Web nor as easy to navigate as dedicated government websites. The value of the archived information also relies on the snapshot being taken at the right time to capture the latest BTP information. The CDC contraceptive-use guidelines purged a few days ago, are available on archive.org from a snapshot taken on 25 December, 2024. Assuming the CDC made no BTP updates since the last snapshot, the information is up to date…for now. Of course contraceptive guidelines evolve with new data and new technology and they will be out of date in the coming years.

If we are to survive the worst damage of The Purge, other government and non-government institutions worldwide will have to step into the breach. Historical data may need to be reconstructed and curated from sources such as archive.org. The Pubmed and Pubmed Central databases should be copied before the US government corrupts them. Where US data are still available, copy them. Outside the US, we will need to put in place prospective mechanisms to collect valuable global data that we can no longer trust from US sources.

…going…

We cannot assume that the facts from US government sources will remain uncorrupted tomorrow because they are uncorrupted today. The preservation of the truth will require resources and investment.

… GONE!

Welcome to The Purge