In December 2001 – less than two months after the al-Qaeda attack on the World Trade Center and not even a month from the day US and UK forces invaded Afghanistan – I was with Act Up Paris as activists carried a banner emblazoned “AIDS: The Other War” to lead their annual World AIDS Day march. Behind the banner, marchers raised signs reminding that more people were dying from complications of HIV every day than were killed on 9/11 in lower Manhattan: “SIDA: 10,000 morts par jour” (AIDS: 10,000 Dead Each Day”). It was not the first time war as metaphor had colored the activist group’s rhetoric; in fact, their response to 9/11 is emblematic of how they combine as truth-telling both careful analysis and bodily provocation, often so unsettling, when confronting powerful elites and emboldened populists. While the portrait of Act Up in the United States has been presented in the 2012 documentary and 2016 book How to Survive a Plague, the stories of Act Up Paris and the challenges French activists faced are largely unknown to the English-speaking public, but that is corrected now that “120 Battements par Minute” (“BPM (Beats Per Minute)” in English) is available to stream in the U.S. This month named the César Best Picture and awarded the Grand Prix at Cannes last year, the fictionalized account depicts the early years of Act Up Paris.
The past week has not been a good one for global health. What gives? I can only come up with one explanation: the Trump Administration is doing its darnedest to disprove the argument in my new book.
In Global Health Governance and International Society (out on the 8th! Perfect for Valentine’s Day!), I argue that the emergence, growth, and ‘stickiness’ of global health politics reflects a shift in an international consensus about our collective obligations to address health concerns in other countries. We’re moving from a largely state-based system that only sporadically considers health matters to one that embraces a wider range of actors in addressing health issues even in the absence of security threats. It’s not perfect by any means, but it’s getting better—and it’s increasingly taking root within international society.
And then the Trump Administration has another one of its terrible, horrible, no good, very bad weeks on the global health front.
First, we have the resignation of Brenda Fitzgerald. Fitzgerald was the director of the US Centers for Disease Control and Prevention, taking office in July 2017. This is perhaps the most prominent public health position in the United States government and has been filled by such luminaries as Tom Frieden, Julie Gerberding, David Satcher, and William H. Foege. If they ever make Public Health Hero trading cards, these folks would be in that pack. (Side note: I’d totally buy Public Health Hero trading cards.) Fitzgerald is unlikely to join that illustrious list. Why? Because Politico reported that Fitzgerald bought thousands of dollars in stocks from tobacco and health insurance companies—while she was the CDC director. Continue reading
The Trump Administration has decided it’s finally time for it to whip out its best George Carlin impression. It’s announced its own list of seven words you can never say—at least not if you are working for the Centers for Diseases Control and Prevention.
In 1972, “Seven Words You Can Never Say on Television” was the last track on his stand-up album, Class Clown. In an interview with Terry Gross in 2004, Carlin explained that the routine was all about calling out hypocrisy and double-standards. There is nothing inherently bad about these words, and keeping them off of the airwaves ignores the context in which they may be used. A later version of this routine even led to a1978 Supreme Court case, Federal Communications Commission v. Pacifica Foundation.
Fast forward 45 years, and the Department of Health and Human Services has apparently announced its own Seven Words You Can Not Include in Documents Prepared for Next Year’s Budget. It doesn’t quite roll of the tongue, and it feels a bit Peppy Bismilk, but its potential effects on science and health policy could be dramatic.
First things first, let’s get the words themselves out in the open. According to Trump’s HHS, the following words are now verboten in CDC budget documents:
Yeah. For real.
According to attendees at the meeting where this policy was announced, the presenter said she was merely relaying information and could not speak to why these words were banned. This appears, though, to be in line with other efforts by the administration to remove certain words and phrases from official documents, such as efforts to scrub information about global warming from the EPA’s website.
Why would the Trump Administration want to keep these words out of official budget documents? From scientific and research perspectives, there is absolutely no reason to do so.
Instead, we have to think about the various purposes that budgets serve. At the most concrete level, budgets tell us how we are going to spend money. The administration is expected to release its budget in February. While no president’s budget is automatically adopted, it can serve as a blueprint for guiding Congress’ efforts to craft a spending plan.
Go a bit deeper, though, and we can start to get a sense of what is driving the Trump Administration. More than just a spending plan, budgets are reflections of our values. This applies if we are talking about households or about national governments. By keeping these words out of budget documents, the administration is not only signalling its research priorities, but also who and what it values.
What does this decision say about the Trump Administration’s health and research values? First, it says that this administration has little interest in understanding or addressing the social determinants of health. When we take the social determinants of health seriously, we recognize that social, economic, and political systems don’t treat everyone equally—and that that inequality has very real consequences for whether a person can lead a healthy life. If you look at the CDC’s current website (quick, hurry before it’s taken down!), there is a section devoted to looking at how and why transgender people have higher rates of HIV infection. It’s not about a trans person’s biology; it’s about issues of stigma, discrimination, and lack of access to care. It’s about social vulnerabilities—oops, there’s a word we can no longer use.
Second, it suggests the administration may be pulling back from the US’ historical global health commitments. The US government supplies roughly one-third of all development assistance for health. It has been a leader in shaping the norms around the importance of supporting global health as a sign of good international citizenship (and if you’re looking for more on that, have I got a book for you! Makes a great Valentine’s Day present!). Part of what that funding has done, though, is support the scientific research to produce the evidence necessary for us to know how to address thorny and difficult global health issues. If we don’t base our policies on evidence and science, we end up with polices that reflect individual biases—things like wasting $1.4 billion on abstinence education programs in Africa even though there is no evidence that they reduce the risk of contracting HIV (and may actually increase it). This is already a problem for US-supported global health programs. Banning science-based and evidence-based will only make the problem that much worse.
Third, it could be another arena in which conservative domestic (and international) politics are taking precedence over improving people’s health. The CDC and other agencies within the United States government have mobilized in an effort to understand the connection between the Zika outbreak in South America and the increase in rates of microcephaly. Scientists don’t understand how or why this connection exists, especially since it hasn’t appeared in other areas where Zika has spread. To understand that, we need to do research on the effects of the Zika virus on pregnant women and their fetuses. The CDC found a definitive link between Zika and microcephaly in 2016, but it will apparently no longer be able to conduct that research. We don’t know why, but it’s possible that it could have something to do with issues surrounding access to birth control and abortion services in Latin America. In many of the countries where microcephaly rates have skyrocketed due to Zika, birth control and abortion are incredibly difficult to obtain. Perhaps this is an effort to appease conservative values—if there’s no research on Zika’s effects on fetuses, there will be fewer calls for changing reproductive laws in the region.
George Carlin used his seven words as part of an effort to encourage free expression and think about the problems arbitrarily limiting speech. The Trump Administration’s seven words will do the opposite. If these are the choices, I’ll take a few curse words any day.
Picture the scene: throngs of people gathering as the night descends. They are looking up at the building across the way—patiently, expectantly. There is a low-hum of voices. Gradually, the voices converge and they begin singing the same song…
When I was 16, I went to Switzerland. It was my first time outside of the US, and I worried about the normal things that a worry-wart teenager might fret about—Where is my passport? (In my handy-dandy passport holder.) Did I remember to get gifts for all of my family members? (Yes, and you’re welcome.) How much fondue can I possibly eat? (Lots, and yet somehow not enough.)
Here’s one thing I didn’t worry about: Am I going to get malaria?
When you think great diplomats—the sorts of folks who can inspire large numbers of people, bring together disparate groups, and raise public awareness of key international issues—Robert Mugabe probably isn’t the first person who springs to mind.
And yet…guess who the World Health Organization just announced as its new goodwill ambassador for noncommunicable diseases in Africa?
Does the international community need a Charlie’s Angels of global health?
You remember Charlie’s Angels. Kate Jackson, Farrah Fawcett, and Jaclyn Smith were three detectives in Los Angeles who worked for a never-seen Charlie. Charlie would call the Angels whenever there was some sort of emergency, and they would go wherever in the world in order to take care of the problem. They were highly competent and glamorous, though we can rightfully criticize the show for emphasizing the Angels’ sex appeal over their crime-fighting skills. I mostly remember the show for being on WGN in the afternoon when it wasn’t pre-empted by the Cubs. (Cubs baseball also frequently pre-empted Super Friends, leading to my distaste for the Cubs to this day…but that’s neither here nor there.)
What happens when three major philanthropies come together to form some sort of global health Voltron?
Mark Zuckerberg, Bill Gates, and Michael Bloomberg are among the world’s most accomplished people. Zuckerberg is one of the founders of Facebook, the social media site we all love to hate. Gates not only has one of the nerdiest mugshots in history, but he’s also the man who unleashed Clippy on the world as the cofounder of Microsoft. Bloomberg created a financial services and technology company, served three terms of mayor of New York City, and even had a cameo on “30 Rock.” They’re also loaded, with a combined net worth of roughly $210 billion.
It’s that wealth that makes them central to the politics of global health. All three have created foundations that have made health central to their missions. The Gates Foundation is the world’s wealthiest foundation, with an endowment of more than $40 billion and spending more than $1 billion annually on global health programs. Bloomberg Philanthropies has made public health one of its five key areas, focusing on issues like tobacco control, improving health-related data, and addressing the unique health challenges in urban areas. The Chan Zuckerberg Initiative, started less than two years ago, is structured less like a traditional charity and more like a tech start-up as it tries to address ambitious goals in health and education.
Microbes are turning into the Borg; our resistance is becoming futile. As any Star Trek: The Next Generation nerd knows (and this is an IR-related blog, so I’m guessing the Venn diagram of DoM readers and ST:TNG fans shows quite a bit of overlap), this is incredibly worrisome for humanity and threatens to give all of us the life expectancies of a red shirt. The international community may yet have a chance to fight back, but it will require both forward thinking and a willingness to cooperate.
The basic problem is the growth of antimicrobial resistance (AMR). An antimicrobial is something like an antibiotic—it kills or inhibits a microorganism like a virus or bacteria, but doesn’t harm the host. When you take penicillin to treat an infection, the penicillin goes after the bacteria causing the infection, but it generally doesn’t cause side effects or do damage to the rest of you. This is what makes antimicrobials so powerful and useful. They gave humanity a fighting chance against infections that had once been a death sentence. With Alexander Fleming’s accidental discovery of penicillin in 1928, health professionals had a powerful tool on their arsenal. Between 1944 and 1972, life expectancy increased by eight years—an increase largely attributed to antibiotics and other antimicrobials.
Ebola is back, but that doesn’t mean that the world should panic.
A little more than a year ago, the World Health Organization (WHO) declared that the West African Ebola outbreak, which killed more than 11,000 people in the largest outbreak of the disease ever, was officially over. On May 11th, WHO announced that the Democratic Republic of Congo had identified 9 suspected cases of Ebola over the past three weeks. Three people had already died, and laboratory testing has confirmed that at least one of the cases has tested positive for the Zaire subtype of the Ebola virus.
I’m not going to lie. When I heard that the Trump Administration was going to release its budget blueprint, I didn’t have high hopes for global health. The new administration’s commitment to global health has been ambiguous at best, and early word was that medical and scientific research was in for some massive cuts.
So what does the budget blueprint tell us about the future the US’ commitment to global health? It’s not all bad. In fact, for a budget that goes so far as to zero out funding for Meals on Wheels, global health comes out relatively well in some very specific ways, but the cuts in medical and scientific research and support are likely to have ripple effects that will ultimately work against the US’ interests in global health. This is a budget that may allow the US to react once crises happen, but it’s not one that will help the US prevent future crises from occurring.
There’s a lot of turmoil in global health governance these days, and it looks like it’s only getting more chaotic. The Global Fund to Fight AIDS, Tuberculosis, and Malaria is hitting the reset button in its quest to identify a new leader “due to issues in the recruitment process”—precisely at a moment when there are real fears about the future of funding for global health initiatives.
What’s happening within the Global Fund may at first glance speak to dysfunction within that specific organization, but it’s better to think of the problems as emblematic of larger questions about legitimacy and the future of multilateralism under the Trump Administration.
Shortly after noon Eastern time in Washington, Donald Trump gave his inaugural address. In it, he proclaimed his desire “to free the Earth from the miseries of disease.” That’s not a bad sentiment. Health is important, the US has played a major role in developing and funding the global health system that currently exists, and there are a host of health challenges that continue to bedevil the world. Trump has made ambiguous statements about his global health commitments in the past, so this is seemingly a good sign. Right? Continue reading
Larry Summers, I’m going to have to disagree with you.
It may seem a bit of a mismatch. Summers is a provocative and influential guy: Chief Economist at the World Bank, Treasury Secretary under Bill Clinton, Director of the National Economic Council under Obama, former president of Harvard University. He helped craft US policy in response to the Global Financial Crisis and international responses to financial problems in Mexico, Asia, and Russia in the 1990s. I, on the other hand, am a random academic whose best-selling book has finally cracked the top 500,000 on Amazon and whose office is adorned with a plush Ebola virus. Since we’re both interested in the politics of global health, though, I think we’ve got something to discuss. I bet we both liked Rogue One, too, so now we’ve got two things to discuss (but we’ll leave the latter for another time). Continue reading
An event happens. Four different people tell four different versions of what happened. How do we figure out how to move forward?
This is a very rough plot summary of Akira Kurosawa’s 1950 masterpiece Rashomon, but it’s also a pretty accurate description of what is happening to the World Health Organization these days. There’s probably a generation of folks who know Kurosawa because he was name-checked in Rent, but the Japanese director also gives us a window for thinking about international politics.
Halfdan Mahler, the Danish physician who served three five-year terms as Director-General of the World Health Organization, died last week in Geneva. Mahler may not be a household name, but he helped to fundamentally transform our collective notions of what global health is and should be. In this moment where WHO is undergoing its own re-examination of its priorities and programs, Mahler’s vision reminds us what could be. He also shows how global health is inextricably linked to international relations and politics.
Mahler’s career mirrors the World Health Organization itself in many ways. He joined WHO in 1951, just three years after it started operations, at a time when it focused largely on disease-specific interventions. His first position was with National Tuberculosis Program in India, where he worked for nearly a decade. From there, he moved to Geneva to oversee WHO’s tuberculosis program and eventually became an assistant director-general.
Two years ago, more people probably knew that Stephen Breyer is on the Supreme Court (hint: it’s a really low number) than had even heard of the Zika virus. I certainly hadn’t, and I make my living studying global health politics. The entirety of published research on Zika could fit in a shoebox. Since the first reports of the virus appeared in Brazil, though, Zika has grabbed international attention, leading to travel warnings and even causing some athletes to pull out of the 2016 Summer Olympics in Rio.
Zika’s emergence changed the dialogue on global health and forced states and organizations to get involved. On 1 February 2016, the World Health Organization (WHO) declared Zika-related microcephaly to be a Public Health Emergency of International Concern (PHEIC). Nine months later, WHO ended the PHEIC for Zika, arguing that the organization should shift to a “robust longer-term technical mechanism.” Is WHO’s decision a reflection of the changing strategy necessary to tackle Zika, or is it evidence that the organization is waving the white flag and admitting defeat?