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?
Well, that was unexpected.
But it’s happened. The question now is, how will the election of Donald Trump change international relations?
I’ve been marking essays for the past week (two big advantages of Australian academia: November is a spring month, and second semester ends before Halloween), and a lot of my students were writing about the right to health and what it would take to realize it in a meaningful sense. That, naturally, led me to thinking about cholera.
Few diseases can kill as rapidly as cholera. That alone should make it a key issue for global health. What makes cholera particularly important and interesting, though, is how much it says about our larger global health system and the interconnectedness between health and other issues.
With any luck, the myth of Patient Zero being responsible for HIV/AIDS in the US will finally be completely put to rest.
Gaétan Dugas may not be a household name for most, but he’s the man who has largely been blamed for HIV/AIDS in the United States. Dugas was a gay French-Canadian airline steward who worked for Air Canada in the 1970s and 1980s. Because his work involved a significant amount of travel and because of the number of his sexual contacts, a 1984 study linked him to some other early cases (though it could not necessarily prove a direct line of infection).
When I walk down the street, I don’t see signs saying “Tedros for WHO” or “Vote Szócska.” The television and radio airwaves don’t have endless campaign commercials ending with the tagline, “I’m Flavia Bustreo, and I approve this message.” Sania Nishtar does not hold large public rallies in sports stadiums to bolster her candidacy. Neither David Nabarro nor Philippe Douste-Blazy do phonebanking.
These facts don’t distract from the fact that there is a vigorous and hotly-contested electoral race for the Director-General of the World Health Organization. Think of the current period as the primaries, with the general election campaign beginning when the WHO Executive Committee forwards the names of the three finalists to the World Health Assembly in February.
When WHO reformed its processes for selecting a new Director-General (which I detailed here), they set themselves up for a new and largely unprecedented experiment. For better or worse, most international organizations select their leaders through fairly opaque processes, and the public gets little glimpse into the decisionmaking process. Even when we have seen multiple candidates competing for the top office, such as the 2012 race for the presidency of the World Bank, the formal campaigns have tended to be brief.
WHO’s election process is different. It is openly contested. It features some of the same trappings of other political campaigns. It requires a degree of public engagement not usually seen in international organizations. The United Nations’ search for a new Secretary-General was supposed to be more transparent, but the process came to a surprising early conclusion when the 15 members of the Security Council announced their unanimous support for former Portuguese prime minister António Guterres.
So far, the WHO DG election does not show signs of ending early. Part of that may be because of the procedures WHO established for the election, but it also reflects the keen interest in the job. When the nomination period closed on 23 September, WHO announced that there were six candidates:
The final list of six surprised a number of observers. Tedros (as he prefers to be called), Douste-Blazy, and Nishtar were not surprises, as all three had essentially been campaigning for months prior to the official nomination period. Bustreo, Nabarro, and Szócska, though, were not among the names being bandied about.
The candidates themselves are an interesting mix. Despite the fact that WHO has been criticized for only having had DGs from Europe or Asia since 1973, only one candidate comes from outside those two regions. Two candidates—Tedros and Douste-Blazy—have served as their country’s Foreign Minister. Bustreo is the only candidate who is currently employed by WHO, but Nabarro headed up one of WHO’s post-Ebola reform panels and previously worked in the Director-General’s office. Nishtar would be the first Muslim to lead the organization if she were selected. Three of the candidates come from traditional donor states to WHO. All but Tedros are medical doctors, while Tedros holds a PhD in community health.
As part of the campaign process, the candidates are reaching out to the voters/member-states. Four of the candidates—Tedros, Douste-Blazy, Nabarro, and Nishtar—have specific campaign websites, and Bustreo and Szócska are active on Twitter. and all six responded to a candidate survey from The Lancet. The African Union announced its support for Tedros’ candidacy (and the value of having an African in the top job) earlier this year. Given that African states are the largest single bloc within WHO, that could give him an early advantage—assuming all AU member-states vote in unison.
All of the candidates appear to meet the basic requirements for the position, so which factors are likely to make a difference in the election? Let me call attention to three issues that are likely to play a big role in the deliberations. First, WHO’s budget is a mess. More than 80 percent of its outlays come from voluntary contributions pledged for specific programs. As a result, WHO has little control over how it spends most of its money, and it lacks the financial flexibility to allow it to respond to an emergency like Ebola. That said, member-states have been reluctant to give WHO more money without seeing proof of WHO’s efficacy. A successful candidate will need to show an ability to simultaneously get WHO the resources it needs to carry out its mission and convince member-states that it can use those funds efficiently and responsibly. There may also be opportunities to develop new financing structures, like UNITAID’s airline ticket levy. (Incidentally, Douste-Blazy has been the chair of UNITAID since 2006.)
Second, WHO needs to restore its international credibility. To a large degree, that is likely to mean that member-states are going to want to know specifics from the candidates about what sorts of reforms WHO will introduce to function better. WHO cannot do everything, so the question is what direction the different candidates would go in their understanding of the organization’s scope. That will also touch on how much autonomy WHO should have: is it there simply to do the member-states’ bidding, or should it have control over its own agenda?
Finally, WHO’s leader will need to show an ability to play politics. Outgoing DG Margaret Chan has been criticized for not being an effective diplomat, especially in contrast to someone like former WHO DG Gro Harlem Brundtland. Like it or not, global health is an inherently political field; a focus on solely on the technical aspects simply will not work in this environment. Indeed, Josh Busby, Karen Grépin, and I argued earlier this year that the next WHO DG specifically needs political experience.
In many ways, the WHO DG election could provide a template for international organizations looking to elect their leaders publicly and transparently. As such, it is all the more important to keep an eye on it—and to pick up some sweet campaign swag.
It should come as no surprise to anyone that a political scientist like me gets really excited about elections and campaigns, and we’re currently in the thick of a doozy of a campaign season. Candidates have splashy websites and brochures, and they regularly meet with voters to pitch their candidacies. Whoever wins will take over an organization whose standing in the world is up in the air—and the winner will have a big job restoring the organization’s place in the larger global landscape.
Of course, I’m talking about the campaign for the next Director-General of the World Health Organization. What else would I be describing?
Why don’t government officials respond to global health emergencies the same way that they respond to national security crises? This is the question Congresswoman Rosa DeLauro (D-CT) raised last week. She was speaking at the public launch of a new report by the Brenthurst Foundation on international society’s failure to respond to the Ebola outbreak in West Africa in a timely manner—but much of the conversation focused on the current response to Zika.
If military officials said they needed $1.9 billion to prevent a global crisis, she argued, Congress would not hesitate to approve the money. Unfortunately, health emergencies don’t receive the same level of attention. “Why aren’t we listening to the generals of public health?” she asked. Instead of making the long-term investments to strengthen health systems and improve detection and treatment capabilities, DeLauro noted, we lurch from one crisis to another.