Category Archives: Global Health

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

A dark, dystopian government data center filled with towering servers and flickering computer screens. Dust-covered books and old research papers sit abandoned, while glowing terminals display files. A lone researcher, illuminated by the cold blue light of a monitor, desperately tries to recover lost data from a corrupted drive. The atmosphere is eerie, with dim overhead lights and an air of secrecy, symbolizing the slow decay of knowledge in a forgotten digital vault.

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

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 Executive 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.

Pandemic schmandemic

I was disconcerted to read that the last of the formal Pandemic Accord meetings for 2024 closed tonight (6 December 2024) without reaching an agreement. My colleague, Professor Nina Schwalbe, summed it up perfectly in her bluesky post. “Member States have missed a once-in-a-generation opportunity to make a difference because national interests prevailed over global solidarity”.

The World Health Assembly established the Intergovernmental Negotiating Body (INB) almost three years ago to “draft and negotiate a convention, agreement or other international instrument under the Constitution of the World Health Organization to strengthen pandemic prevention, preparedness and response”. When the WHA established the INB, we were in the middle of the COVID-19 pandemic. There was a visceral urgency to figure out better ways to work together globally to prevent and manage the next pandemic. Now, it’s all a bit “meh“.

In the last month, we have been gifted non-ignorable data points by the fates, which should have focused the mind. We did not need special skills to read the tea leaves at the bottom of the cup or divine the future from goat entrails.

  1. The American people re-elected Donald Trump as President of the United States and handed him a clear mandate. He campaigned on a populist America First policy and has declared (and demonstrated) an antipathy towards global treaties and accords that threaten global health.
  2. Trump also announced that Robert F. Kennedy Jr. (RFK Jr), a vaccine denier, would be the Health Secretary. RFK Jr is also on record that there is too much focus on infectious diseases.

Together, these will create geopolitical friction in negotiating a pandemic accord that may be impossible to overcome. Fate has also been teasing us with news of infectious diseases among those geopolitical tea leaves.

  1. A mystery infectious disease has appeared in a remote area of the Democratic Republic of Congo. According to the Ministry of Public Health, there have been 394 cases and 30 deaths.
  2. Influenza A subtype H5N1 is the stuff of infectious disease specialists’ nightmares. It has a very high case fatality rate–typical ‘flu’ has a fatality rate of <1%. H5N1 has a case fatality rate of around 50%. The saving grace has been that it had not adapted to human-to-human transmission. Human transmission might be about to change. It has swept through U.S. dairy herds and is found in raw milk. Did I mention that RFK Jr. is a fan of raw milk?

This failure is particularly bitter because they’re walking away from the negotiating table when the stars are aligning for potential future crises. We have a new U.S. administration openly sceptical of global health cooperation, an increasingly complex geopolitical landscape, and emerging pathogens testing our surveillance and response capabilities. The window of opportunity that opened during COVID-19–when the world’s attention was focused on pandemic preparedness–appears to be rapidly closing.