Tag Archives: Global Health

The Great Trade Experiment

Last month I wrote about The Great Foreign Aid Experiment of the Trump administration. Foreign aid has not been without its critics because it is inefficient, promotes corruption, or is a part of an insidious program of neo-colonialism. The decision, however, by the US Government to put foreign aid “through the wood chipper” sets up a natural experiment to test whether aid save lives—more precisely, whether the sudden removal of aid ends lives. Most people in global health believe that it will result in significant suffering, although some see a silver lining: deaths among the poor and vulnerable will mark the emergence of independent health systems in low-income countries that are more resilient and finally free of external interference.

Not content with one natural experiment at the expense of the global poor, on the 2^nd of April 2025, Donald Trump announced the imposition of the highest rate of tariffs on US imports in almost 100 years. In effect, the government is dismantling the free-trade mechanism that has been operating since the mid-1990s, and adopting a more isolationist market posture. Under this new theory of trade, wealth is not created, it is finite and accrued by one country to dominate another.

The evidence has been pretty clear about the effects of poverty on health. Poor people are more likely to die than rich ones. Infant, child, and maternal mortality rates are significantly higher among the poor. Preventable and treatable diseases such as HIV, tuberculosis, and malaria also disproportionately infect and kill the poor. These poverty effects occur both within and between countries. Furthermore, they are not just biological outcomes—they are deeply social, economic, and political in nature. The conditions of poverty limit access to healthcare, nutrition, education, and safe living environments.

Over the last 75 years, in parallel with increasing life expectancy across the globe, wealth has also increased. The proportion of people living in extreme poverty today is much lower than it was 50, 20, or even 10 years ago. In fact, historically the sharpest global decline in extreme poverty occurred between 1995 and 2019—2020 was, of course the COVID pandemic, which reversed a wide rage of health and economic indicators.

Bill Clinton assumed the presidency of the United States in January 1993. He was supportive of free trade and the Uruguay Round of of the General Agreement on Tariffs and Trade (GATT), which was completed in 1994. The successful conclusion of GATT led to the creation of the World Trade Organization (WTO) in January 1995.

Following the liberalisation of trade, global extreme poverty rates fell from 36% to 10% between 1995 and 2018. In South and South-East Asia the extreme poverty rates fell from 41% to 10%. In Sub-Saharan Africa, the extreme poverty rates fell substantially, but without the same speed or depth as elsewhere: 60% to 37%. The gains of trade liberalisation were also more advantageous to some markets than others, and it particularly benefited countries with cheap manufacturing capacity such as Bangladesh and Cambodia.

The sudden US reversal on tariffs will be punishing for those poor countries that have developed a manufacturing sector—particularly in shoes and garments—to provide cheap, volume goods based on low labour costs. Of course, the goods in the US need not be cheap, because there is considerable profit in branding.

If exports drop significantly, factories will want to cut staff numbers swiftly to retain their commercial viability. Poor households, particularly those reliant on a single income manufacturing jobs, will likely be thrown backwards into extreme poverty. The global economic gains of the last 30 years could begin to reverse. A major drop in exports will have an immediate impact on the factories’ labour force but there will be flow on effects to the entire economy of poor countries. In Bangladesh, for example, garment manufacturing is the single biggest source of export revenue, and reductions here will mean reductions in national tax revenue which supports health, education and welfare services.

In other LMICs that are less reliant on a global export market, shifts in tariffs will have a concomitantly smaller impact. Thus, the two natural experiments will intersect. The impact of foreign aid on health and the impact of foreign trade on health will play out with interacting effects.

Needless to say, none of this was ever framed as an experiment. Cutting aid and raising tariffs was all to “Make America Great Again”. It is a cruel, indifferent approach to trade and foreign policy. There will be no one in the Situation Room plotting a Kaplan-Meier survival curve. No policymaker will announce that the hypothesis has been confirmed/rejected: that wealth, when withdrawn or walled off, leaves people dead. Nonetheless, the data will tell its own story.

And when it does, it won’t speak in dollars or trade deficits. It will speak in the numbers of anaemic mothers, closed clinics, empty pharmacies, and missed meals. It will speak in children pulled from school to help at home. It will speak in lives shortened not by biology, but by policy

The Great Trade Experiment, like the Great Aid Experiment, won’t just test theories in global health and economics. It will test people—millions of them. And the results, while statistically significant, will not be ethically neutral. Some experiments happen by accident. Others, by design.

This one was designed—by the President of the United States.

Parasitising Human Rights

A snail glides slowly from the shelter of the underbrush into the sunlight. One of its eye stalks (ommataphore) pulses with an unnatural rhythm, swollen, brightly coloured and weirdly attractive. A thrush spots the movement and swoops down, drawn to the flickering lure, pecks off the stalks and flies away.

The thrush was fooled. What it mistook for a juicy caterpillar was a parasite seeking a new host. The parasite, Leucochloridium paradoxum, is a trematode that infects a snail and turns it into a self-destructive zombie. The life cycle is simple: bird eats parasitised snail, parasite reproduces in bird’s gut, bird defecates, snail eats infected droppings. Once the parasite has been eaten by the snail, it hijacks the snail’s behaviour. It migrates to the snail’s eye stalks and drives it out of the safety of the underbrush and into the sunlight, where it will lure a bird to eat it. Rinse and repeat.

It was only very recently that I realised that the Christian far-right groups had adopted an analogous strategy to attack the international human rights framework and women’s rights in particular.

The Geneva Consensus Declaration (GCD) and its companion, the Women’s Optimal Health Framework (WOHF), function with unnerving similarity to the apparently tasty snail. They are each packaged in the shiny and appealing language of “optimal health”, “human dignity”, and “family”. They infiltrate the human rights system—not to strengthen it, but to hijack it, disguising regressive aims as a legitimate rights discourse. Once absorbed by a State-host, the State is zombified to re-present the regressive framework in shiny, deceptively appealing language waiting to parasitise the next State.

The GCD was first presented to the United Nations as a letter under Donald Trump’s 45^th Presidency of the United States. It was an initiative of the Secretary of State, Mike Pompeo, a fundamentalist Christian. Borrowing the name of the City of Geneva, made famous by its association with refugees, human rights and the Geneva Conventions, the GCD is neither supported nor endorsed by Switzerland nor the the Republic and Canton of Geneva, nor is it adopted by the UN.

The GCD document opens with lofty and appealing commitments to universal human rights and gender equality—pulling deceptively and disingenuously on the Universal Declaration of Human Rights. It declares that “all are equal before the law” and that the “human rights of women are an inalienable, integral, and indivisible part of all human rights and fundamental freedoms”.

Once consumed, there is a parasitic turn. The GCD reverts to a framework that reduces women to vessels and vassals in service to cells and states. The foetus is elevated. It is endowed with rights that eclipse those of the woman herself. She becomes a fleshy bag—nutrients in, baby out—stripped of the autonomy to define her own purpose or direction. The role of the State shifts. It is no longer the guarantor of individual freedom but the authority that dictates what a woman may or may not be allowed to do. “The family”—a surprisingly labile cultural concept—is suddenly reified, declared “the fundamental group unit of society,” as if its meaning were fixed and universal. The document commits fully to a vision of a society where the population serves the State, and women serve the population—with the least autonomy.

Health is a human right as is the right to healthcare. The GCD and the WOHF want to parse this, playing a game of reductio ad absurdum. You might have a right to healthcare, they argue, but you do not have a right to an abortion. As if it makes sense to say you have a right to healthcare, but not if you have scabies, rabies, HIV, or malaria. Pregnancy is not a disease, but it does require healthcare and that care may include the termination of the pregnancy. A woman’s purpose is not reproduction—servitude to a foetus.

Men, too, are caught in the parasitic zombification. They should not mistake their apparent elevation in these structures for freedom. They lose something fundamental. Choice. Authoritarian gender orders assign roles to everyone. Power is not granted—it is rationed and always conditional. The State grants status for obedience and identity in exchange for submission. Those assigned dominance are especially bound by its terms. This constraint brooks no dissent. In a society of freedom, you can find your own place. In a society of roles, your place determines you.

These zombified States do not act alone. The US-backed Institute for Women’s Health promotes the destruction of women’s rights, replacing evidence with sleek visuals and rhetorically based policy tools. The materials are presented as neutral frameworks but embed deeply conservative ideologies—valorising motherhood, framing women’s worth through familial roles, and avoiding any substantive discussion of sexual rights.

States that adopt these frameworks serve as megaphones, amplifying anti-abortion and anti-diversity policies in UN negotiations and global fora. This is not a grassroots movement for gender justice. It is a top-down project of moral, political, and social control, disguised as health policy.

The GCD and WOHF are not neutral initiatives. They are a parasitic ideological vehicle that masquerades as progressive while advancing regressive policies. Their true function is to infiltrate human rights systems, hijack the language of empowerment, and turn States into agents of restriction.

We must name this strategy for what it is: a parasitic ideology—designed to deceive, manipulate, and replicate. Human rights advocates must remain alert, resist co-option, and expose these frameworks not just for their content, but for the insidious strategies they deploy.

The only antidote to such parasitism is clarity, resistance, and the refusal to surrender universal human rights to the State.

Local causation and implementation science

If you want to move a successful intervention from here (where it was first identified) to there (a plurality of new settings), spend your time understanding the context of the intervention. Understand the context of success. Implementation Science—the science of moving successful interventions from here to there—assumes a real (in the world effect) that can be generalised to new settings. In our latest (open access) article, recently published in Social Science and Medicine, we re-imagine that presumption.

As researchers and development specialists, we are taught to focus on causes as singular things: A causes B. Intervention A reduces infant mortality (B1), increases crop yields (B2), keeps girls in school longer (B3), or…. When we discover the new intervention that will improve the lives of the many, we naturally get excited. We want to implement it everywhere. And yet, the new intervention so often fails in new settings. It isn’t as effective as advertised and/or it’s more expensive. The intervention simply does not scale-up and potentially results in harm. Effort and resources are diverted from those things that already work better there to implement the new intervention, which showed so much promise in the original setting, here.

The intervention does not fail in new settings because the cause-effect never existed. It fails in new settings because causes are local. The effect that was observed here was not caused by A alone. The intervention was not a singular cause. A causes B within a context that allows the relationship between cause and effect to be manifest. The original research in which A was identified had social, economic, cultural, political, environmental, and physical properties. Some of those properties are required for the realisation of the cause-effect. This means that generalisation is really about re-engineeering context. We need to make sure the target settings have the the right contextual factors in place for the intervention to work. We are re-creating local contexts. The implementation problem is one of understanding the re-engineering that is required.

The cartographic challenge of decolonising global health

A navigational chart from the Marshall Islands, on display at the Berkeley Art Museum and Pacific Film Archive. It is made of wood, sennit fibre and cowrie shells. From the collection of the Phoebe A. Hearst Museum of Anthropology at the University of California, Berkeley. Date not known. Photo by Jim Heaphy. (Wikipedia; CC BY-SA 3.0)

There are a growing number of papers in the peer-reviewed literature about decolonising global health (see). Pascale Allotey and I have discussed the problem in terms of “trickle-down science” (also see). That is, the way (global health) science is done, how it is prioritised, and who is advantaged. It is a description of science generally conceived and managed from powerful institutions in the global north, with implementing partners in the global south, their factories for data collection. We have also critiqued critiques that advocate a utopic version of global health, arguing that:

decolonising global health extends beyond relations between [low- and middle-income countries] LMICs and [high-income countries] HICs; it is also about the relationships within them. Decolonisation is fundamentally about redressing inequity and power imbalance.

The latest offering on the altar of peer review is a three-step roadmap to the decolonisation of global health and a call to join the authors on their journey. Maps, however, are tricky things. They are culture-bound and themselves tools of colonisation. Their design, content, and what they highlight and ignore require a shared and agreed understanding of the path and the goal. Woe betide the European sailor trying to navigate using the Marshall Islands stick chart.

Much as I applaud the idea of redressing the power imbalance in global health, this particular attempt is tone-deaf. It is presented as if decolonisation was waiting for six authors from three of the world’s wealthiest countries to explain it to “the colonies”. Readers will forgive the irony that the first and last authors of the roadmap are at the London School of Hygiene and Tropical Medicine (LSHTM) — an institution established to support the colonial administration of the world’s greatest empire — an institution that, to this day, encourages and benefits from neocolonial relationships with the global south. The authors note these kinds of relationships and bravely forge on.

In developing the roadmap, the authors draw parallels with the feminist movement. An apt analogy (tongue firmly in cheek) because who cannot recall the importance to the feminist movement of first having men in power explain how it should be done? The men were so quick to relinquish their power that one barely remembers the days of gender inequality. Who does not know (tongue back behind teeth) that women of privilege often powered the first and second waves of feminism? The movement systematically failed to account for class differences, colour lines, and culture — leaving many women behind—the voice matters.

Who has the right to speak for whom in global health is a challenge. In a previous article, I wrote about this very issue. Fighting over the legitimacy of the voice is always fraught, and passions can run high. Are voices from some countries/institutions with this or that history as a colonial master or servant more or less valued than others? Is it more or less hypocritical to privilege voices from LSHTM, Johns Hopkins University, or the University of Washington over those from Makarere University, the Tata Institute of Social Sciences, or the Oswaldo Cruz Institute?

“Decolonising” is ultimately about forgoing power and transferring power. It is something that has to happen between countries and within countries. There is a cacophony of voices, all of which should be heard — but they are not equally important. They do not all warrant the same time and space. The authors of “the roadmap” are neither transferring nor forgoing power. As the cartographers, they determine the path, the points of interest, and the rest stops.

The roadmap for decolonising global health should not be determined nor led by countries and institutions simultaneously holding the whip and the chum.

#decolonising #decolonising #globalhealth.

With any piece I write about decolonising global health, I always have two competing voices in my head: “this issue is important, say it” and “should I be the one saying it?” I will declare my conflicts, and you can decide if you want to listen to or shoot the messenger. I am a white male born in (not by choice) the British Colony of Southern Rhodesia. In virtue of privilege and choice, I have lived and worked in Australia and the UK, and for the last 12 years, Malaysia and Bangladesh. My partner and I moved to Southeast Asia. Then I moved to South Asia because we were committed to capacity building and decided it was no longer appropriate to work in the global health space while sitting in a high-income country. I have never held appointments at LSHTM, Johns Hopkins University, or the University of Washington.

The original article was first published on medium.com on 26 March 2021. This version is very slightly edited.