Category Archives: Equity

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

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 He has withdrawn life-saving medicines from millions of people around the world and declared ethnic cleansing a US policy.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 Ex e cutive 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.

U.S. withdrawal from W.H.O.

A few days before Christmas, the Financial Times reported that the Trump transition team will pull the United States out of the World Health Organization (W.H.O.)—on day one. This is not the first time Trump has made this threat, and all indications are that he will make good on the promise. The U.S. withdrawal from W.H.O., while challenging, may also present an opportunity. Never let a crisis go to waste.

The Financial Times report about the U.S. withdrawal generated significant heat in social media. However, the actual level of threat (and the opportunity it offers) needs to be put into perspective. We can assume that the Director General, Dr Tedros Adhanom Ghebreyesus, started planning for the possibility of a U.S. withdrawal prior to the November presidential election. Once the result was known, W.H.O. would have looked at it’s options in earnest, and in 12 days time, W.H.O. will be able to respond positively and proactively. At least, this is the hope. And if the new Trump administration doesn’t withdraw, the plans can be quietly shelved.

A significant loss of funding will necessitate reform. Because a multilateral agency like W.H.O. is not a commercial entity it does not have the same singular focus: make money. U.N. Agencies simultaneously pursue diverse (sometimes unaligned) positive outcomes. The sustainable development goals are a hallmark of this tension: economic growth, sustainable cities and communities, responsible consumption, climate action,… save the planet. Thus, any reforms required by substantial changes in funding must navigate a complex web of member states’ competing priorities and interests. These complexities include balancing the divergent needs of countries that vary on economic, political, social, economic, demographic, and geographic profiles. There are, nonetheless, strategic lessons to be learned from past crises in large complex organisations. Know your core business (even if it is a portfolio of activities), focus on delivering that, do it efficiently.

A good place to start is by acknowledging that W.H.O. is not a bastion of lean and efficient administration. Even the most ardent defenders of W.H.O. are under no illusions that it is an organisation with structural problems. There are, for instance, critical thematic overlaps in the organisation’s activities. These overlaps occur between W.H.O. departments, and between W.H.O. and other multilateral agencies and international non-government organisations (INGOs). The overlaps create significant inefficiencies in the delivery of global health. Given the health threats we face, a less entrenched, more agile agency would benefit the world. And the U.S. withdrawal could provide that opportunity.

The U.S. provides about 20% of total revenue. As such, the Director General should not let the opportunity for reform afforded by the U.S. withdrawal go to waste. A budget black hole is a perfect reason for institutional reform. Something has to go, if you no longer have the money to do all the activities you were doing before. Some reform will be short, sharp and unpleasant—dictated by the exigencies of circumstance, and some can be more gradual. If the planning process has been done properly, as W.H.O. prepared for the Trump presidency, it should all be strategic.

Focus reform on staff numbers and practice, and programmatic inefficiencies and overlaps. Engage in a strategic redundancy exercise. Renegotiate Staff Association rules that protect poor work practices—W.H.O. staff are international civil servants, not recipients of sinecures. Identify core current business and core future business, and focus effort there. Leave other agencies and INGOs to look after non-core business. Regardless of the reform outcome, W.H.O. can use its substantial convening power to ensure that the coverage of key health areas is not lost but redistributed and shared—this will prevent fragmentation. The funding crisis should also be used as a clarion call for member state financial support and for member state support of the institutional reform process. The loss of U.S. funding is also a political opportunity to push back against member states adopting purely transactional relationships with W.H.O.. Draw a line in the sand. Send the message, “You will not bully us”, and any countries’ efforts to destroy global health will be resisted.

In 2011 U.N.E.S.C.O. faced a funding shortfall following the granting of full membership to Palestine. The organisation went through the strategic process of terminating or scaling back low priority programs. They trimmed administrative and operational activities to focus on key deliverable priorities. They sought to diversify funding.

There are risks associated with any institutional reform process. The risks, however, are most obviously associated with a voluntary reform process rather then one forced on the organisation by circumstance—hence, the notion of never letting a crisis go to waste. The biggest internal risk is the alienation of staff by changing long-standing employment practices. The risk is unsought (staff will understand that) and needs to be balanced against the even greater risk of sinking into a sea-of-debt by failing in a broad fiduciary duty to member states and beneficiaries. Staff reforms will require open and transparent engagement with the staff association, which can be enhanced by member states supporting affected nationals. The greatest external risk is a dilution of W.H.O.’s mission and the further fragmentation of global health efforts.

Reforms must be approached judiciously and collaboratively, ensuring that W.H.O.’s core mission and credibility as a global health leader are not compromised. Goodwill (not the U.S.’s) is on W.H.O.’s side. Historically, it has been a massive global good. Is it imperfect? Yes. Does it get things wrong? Sure. Can it be improved? Absolutely. The measure of W.H.O. is not in its failures but in its successes: the eradication of smallpox; the elevation of HIV/AIDS as a global problem; the African Programme for Onchocerciasis Control; the worldwide reduction of infant and child mortality; and the coordination role in the COVID-19 pandemic. None of these successes are W.H.O.’s alone, and that redounds to the ultimate value of the organisation. W.H.O. is the multilateral space that promotes global health. It is the only global health organisation empowered by 194 (err…193) member states to promote global public health, set international health standards, provide leadership on health matters, and coordinate international efforts to prevent and respond to health emergencies.

If the U.S. does withdraw, it is almost impossible to imagine that any alternative organisation could be proposed. A world health organisation by any other name would be similarly exposed to capricious withdrawal by a member state responsible for significant funding. The remaining member states need to double-down on their commitment and support a reform process, or risk a collapse in coordinated global health efforts.

While I am being so generous with my unsolicited advice, I also have a humble suggestion for the speech Dr Tedros should make if the Trump team make good on its promise to withdraw. I was “inspired” by the speech given by the U.K. Prime Minister (Hugh Grant) to the U.S. President (Billy Bob Thornton) in Love Actually.

The United States has been a cornerstone of global health efforts—a key partner since 1948. But let me be clear. The World Health Organization is not a convenience. Nor is it a platform for unilateral decisions and capricious withdrawal. It exists not for the benefit of any single nation but for the collective good of all nations—nations coming together to confront challenges that no country can solve alone.

We have eradicated smallpox. We have led the global fight against malaria and polio. We led the Safe Motherhood Initiative. These achievements are not ours alone but the result of countries uniting for the common good.

For any country to withdraw at this time, in this world of increasing threats, is to risk undoing decades of progress that have saved millions of lives and improved the lives of millions more.

A global partner who turns away in times of shared need is no longer acting as a partner, and while we have valued past support, we will not be bullied into abandoning our values and principles. To withdraw is to selfishly turn one’s back on a shared responsibility, risking decades of progress globally and within the United States.

Diseases and crises do not respect borders.

While the decision by the President will have the greatest impact on the most vulnerable, let me assure you: W.H.O. will remain steadfast in its mission to protect those who need us most. We exist to ensure health for all, especially the most marginalised, and we will not waiver in that responsibility. We have faced crises before, and in crisis lies opportunity. We will adapt, persevere, improve, and deliver life-saving support—not for our survival, but to safeguard the lives and well-being of the world’s most disadvantaged communities—including those communities in the United States.

A Christmas Story

In the last year of the reign of Biden, there was a ruler in Judea named Benyamin. He was a man of great cunning and greater cruelty.

In those days, Judea, though powerful, was a vassal state. Its strength was created through alliances with distant empires. It wielded its might with a fierce arm and harboured a deep hatred for its neighbors. Benyamin, fearing the loss of his power, sought to destroy the Philistines on that small strip of land called Gaza, and claim it for himself.

For over four hundred and forty days and nights, he commanded his armies to bomb their towns and villages, reducing them to rubble. The Philistines were corralled, trapped within walls and wire, with no escape. Benyamin promised them safety in Rafah and bombed the people there. He offered refuge in Jabalia, and bombed the people there.

In Gaza, there was no safety and there was no food.

Even as leaders wept for the Philistines, they sold weapons to Benyamin and lent him money to prosecute his war. Thus, the world watched in silence as the Philistines endured great suffering. Their cries rose up to heaven, seemingly unanswered.

And so it came to pass, in the last days of the last year of Biden, there was a humble Philistine named Yusouf born of the family of Dawoud. Before the war, Yusouf had been a mechanic. He worked hard each day fixing tires and carburetors, changing break-pads and exhaust systems. And at the end of each day, he would return home to his young wife, Mariam. The same Mariam, you may have heard of her, who was known for her inexhaustable cheerfulness.

That was before the war. Now Mariam was gaunt and tired, and heavy with child.

On the night of the winter solstice, in a dream, a messenger came to Yusouf. “Be not afraid, Yusouf”, the messenger said. “Be not afraid for yourself, for the wife you love so very much, or for your son—who will change the world. What will be, will be and was always meant to be”. Yusouf was troubled by this dream, and found himself torn between wonder, happiness, and fear. Mariam asked him why he looked troubled, but he said nothing and kept his own counsel.

The following night the same messenger visited Mariam in her dreams. Mariam was neither afraid nor troubled. The next morning she had a smile on her face that Yusouf had not seen for so long he had almost forgotten it. “It is time, Yusouf”, she said. “We have to go to the hospital in Beit Lahiya.”

Yusouf was troubled. Long ago he had learned to trust Mariam, but his motorbike had no fuel and it was a long walk. Too far for Mariam, and they were bombing Beit Lahiya. He remembered the words of the messenger in his dreams and he went from neighbour to neighbour. A teaspoon of fuel here, half a cup there. No one demanded payment. If they had any fuel, no one refused him. Having little, they shared what they had. It was the small act of kindness that binds communities. Yusouf wept for their generosity.

When he had gathered enough fuel, he had Mariam climb on the bike. Shadiah, the old sweet seller who had not made a sweet in over a year and could barely remember the smell of honey or rosewater, helped her onto the back.

Yusouf rode carefully. He weaved slowly around potholes and navigated bumps. In spite of his care, he could feel Mariam tense and grip him tighter. And then the motorbike stopped. A last gasping jerk and silence. The fuel was spent.

The late afternoon air was cooling as he helped Mariam walk towards the hospital. When they arrived at the gate, a porter stopped, them. “They’re evacuating the hospital. You can’t go in”, the porter told them. Yusouf begged. “My wife, she is going to give birth,” he told the porter—who could plainly see this for himself. The porter looked at Mariam and took pity. “You can’t go in, but there is a small community clinic around the corner. It was bombed recently, but some of it, a room or two, is still standing. I’ll send a midwife.”

Yusouf gently guided Mariam to the clinic. He found an old mattress on a broken gurney and a blanket. He lay it on the floor and settled Mariam.

If there had been a midwife—if she had ever arrived… if she had ever got the porter’s message—she would have been eager to retell the story of the birth. Sharing a coffee, with a date-filled siwa, she would have painted the picture. Mariam’s face was one of grace. Yusouf anxiously held her hand. The baby came quickly, with a minimum of fuss, as if Mariam was having her fifth and not her first.

Yusouf quickly scooped up the baby as it began to vocalise it’s unhappiness with the shock of a cold Gaza night. He cut the cord crudely but effectively with his pocket knife. And it was only as he was passing the the baby to Mariam that he looked confused. He did not have the son he was promised, he had a daughter. The moment was so fleeting that quantum physicists would have struggled to measure the breadth of time, and Yusouf smiled at the messenger’s joke.

Because there was no midwife to witness this moment, we need to account for the witnesses who were present. There was a mangy dog with a limp looking for warmth. He watched patiently and, once the birth was completed, he found a place at Mariam’s feet. There were three rats that crawled out of the rubble looking for scraps. They gave a hopeful sniff of the night air and sat respectfully and companionably on a broken chair. As soon as the moment passed, they disappeared into the crevices afforded by broken brick and torn concrete. Finally, there was an unremarkable cat. In comfortable fellowship, they all watch the moment of birth knowing that, tomorrow or the next day, they were mortal enemies, but tonight there was peace.

“Nasrin”, Yousuf whispered in Mariam’s ear as he kissed her forehead. “We’ll call her Nasrin.” The wild rose that grows and conquers impossible places.

There was a photo journalist called Weissman, who heard from the porter that was a very pregnant woman at the clinic. “She’s about to pop”, the porter said. Weissman hurried to the bombed out clinic so that he could bear witness to this miracle in the midst of war.

He missed the birth. And when he arrived, he did not announce his presence. It seemed rude. An intrusion on a very private moment. It did not, however, stop him from taking photos for AAP.

He later shared those images with the world. Yusouf lay on the gurney mattress, propped against a half destroyed wall. Mariam was lying against him, exhausted, eyes closed, covered in a dirty blanket. The baby Nasrin was feeding quietly, just the top of her head with a shock of improbably thick dark hair peeking out. Yousuf stared through the broken roof at the stars in heaven. The blackness of a world without electricity made resplendent. He looked up with wonderment and contentment on his face. He was blessed, he thought. No. They were blessed. The messenger was right.

As Weissman picked his way in the dark towards the hospital gate, where he had last seen the porter, he shared the same hope that he had seen on Yusouf’s face. New life can change things.

The night sky lit up, brightening his path to the hospital. He turned back and was awed by a red flare descending slowly over the remains of the clinic as if announcing a new beginning to the world. A chance for something different was born here today.

The explosion shook the ground and Weissman fell. Cement and brick dust from where the clinic had stood rose sharply in to the air. An avalanche of dust raced towards him.