Week 13

The History of Health Institutions and Players

• The intentional effort to influence health in low-income countries has existed for several centuries.

Colonial or Tropical Medicine

• Focused on protecting colonizers from tropical diseases.
• Less emphasis on protecting indigenous populations from diseases introduced by colonizers or safeguarding public health in general.

Transitions After World War II

• Founding of the World Health Organization (WHO).
• Many colonized nations gained independence.
• International health framework: Wealthy countries provide financial and technical aid to improve health in poorer countries.
• Shaped by dynamics of tropical medicine era due to former colonizer/colony relationships.

Multilateral Organizations

• Affiliated with the UN.
• Mandate: Set norms/standards, shape global research, provide technical support, monitor disease trends.
• Every country has one vote.
• WHO's influence has waned over time.
• UNICEF is highly involved in child survival and immunization programs and has a substantial budget.

US Withdrawal from WHO

• Potential catastrophic effects on domestic and global health due to severing ties and reduced funding.
• The US was the largest donor, contributing between 163 million and 816 million annually over the past decade, with 1.28 billion in 2022-2023 (16% of WHO's total revenue).
• 79% of US contributions were voluntary and earmarked for specific initiatives like responding to health emergencies, expanding health services, eradicating polio, and preventing epidemics.
• The Trump administration directed the CDC to cease communications with the WHO, threatening the exchange of critical data and expertise.

Multilateral Financial Organizations (Bretton Woods Organizations)

• Believe markets are the best way to deliver healthcare.
• Provide loans to countries expected to generate a return on investment.
• Voting power is proportionate to economy size; the US has effective veto power.
• World Bank.
• International Monetary Fund (IMF): Steps in during financial crises.
• Structural adjustment programs: privatization of national industries and government payroll cutbacks.

IMF Lending

• The IMF lends to over 90 countries worldwide

Voting Share

• US holds just under 16% of the vote in the International Bank for Reconstruction and Development

US Influence

• US withdrawal would surprise experts and investors, as the institutions give Washington that influence at a relatively low cost.
• Stepping back would be a gift to China and others seeking to dislodge it as the global leader.
• China has been keen for a larger role in global groups.
• China's current share is just over 5%.

US Participation Review

• The Trump administration is reviewing US participation in the World Bank and IMF, with a review projected to come in August.
• US withdrawal from both is possible.
• IMF/World Bank spring meetings are discussing the financial impact of the US tariffs on the global market.

Other Major Players in Global Health

• Bilateral Organizations: Aid agencies created by governments to assist other governments (e.g., USAID).
  • Often have political goals benefiting the donor government's military or economic interests.
  • US withdrawal impacts this significantly.
• Private Foundations: Bill & Melinda Gates Foundation, Rockefeller Foundation.
  • Donate to WHO, NGOs, and develop their own agendas.

Health Aid

• Governments of many low-income countries rely on donor funding for a large portion of their Ministry of Health (MoH) budget.
• Donor constraints make it difficult for low-income countries to set their own health priorities.
• Donor funding often runs on a 2-3 year cycle, hindering long-term planning by MoHs.

A Short History of US Foreign Aid

• 1910/1920s: US sends food to war-torn Belgium and supports relief for the Russian famine.
• 1940s: Post-WWII, the US creates the Marshall Plan in 1948 to rebuild Europe’s economy.
• 1960s: Congress passes the Foreign Assistance Act, creating USAID in 1961.
• 1980s: Downward trend in US foreign aid.
  • Reagan introduces the Global Gag Rule, prohibiting US funds to support organizations that provide abortion referrals or information.
• 1990s: USAID staff capacity suffers due to downsizing, agency shifts to managing large grants and contracts through US NGOs and for-profit businesses.
• 2000s: George W. Bush reinstates the Global Gag Rule (Mexico City Policy).
  • Bush makes development one of three pillars of US national security.
  • Bush creates PEPFAR in 2003 to provide medications to people with HIV/AIDS.
• 2000s (continued): Bush creates the Millennium Challenge Corporation (MCC) in 2004.
  • Barack Obama repeals the Global Gag Rule in 2008.
• 2010s: Obama signs the US Presidential Policy Directive on Global Development.
  • Reinforces the role of development alongside defense and diplomacy in US national security.
  • Congress passes the Global Food Security Act and the Foreign Aid Transparency and Accountability Act in 2016.
• 2010s (continued): Donald Trump is elected in 2016 and reinstates the Global Gag Rule in 2017, expanding it to all US global health programs in 2020 (Protecting Life in Global Health Assistance - PLGHA).
  • Trump freezes federal hiring and eliminates thousands of positions.
• 2020s: Global Gag rule repealed as one of the first steps after Biden took office.
  • Biden budget proposal in 2021 included 63.8 billion for diplomatic engagement & foreign assistance
  • As of December 2022, PEPFAR had provided treatment to more than twenty-five million people.
  • 1 billion+ pledged in new funding towards humanitarian assistance for those affected by Russia’s war in Ukraine
• 2020s: Shift in funding and operations
  • US withdrawal from WHO, potential cancellation of PEPFAR, cancellation of USAID
  • Conflict over money that Congress had already appropriated; many challenges currently in the courts
  • Major shift in rhetoric

Global Gag Rule

• Predictable piece of US foreign policy leading to loss of funding, misunderstandings, and a chilling effect.
• Also results in interrupted HIV/AIDS care.

Role of the United States in Global Health

• As a donor: Financial investments in health.
• Role within the United Nations & NGO donor.
• USAID, PEPFAR, & other US-run programs.
• As a superpower: Economic policy, military policy

Foreign Aid Perception vs. Reality

• The average American believes 26% of the federal budget goes to foreign aid; it's really around 1%.
• The US is the largest single foreign donor, but as a percent of GDP, US aid spending is near the bottom of all OECD countries.

Aid Target

• Most rich countries fall short of 0.7% aid target
• Only five countries meet a UN target of 0.7 percent of gross national income for international development spending

US Government Spending

• Poverty focused development aid makes up 0.49% of the US government spending.

Top Countries Receiving Foreign Aid (2022)

• Economic aid accounted for 86% of foreign aid obligations by the U.S., while military aid accounted for 14%.

Cumulative US Foreign Aid 1946-2024

• Provides a breakdown of which countries have received the most cumulative aid from the US since 1946, both economic and military.

Cuban Medical Diplomacy

• Soft power is an international approach to diplomacy whereby a nation seeks to influence other nations and gain greater stature and impact via attraction and persuasion rather than coercion or force
• Historically soft power has been a significant part of the US foreign aid policy – this is currently dramatically shifting
• How does Cuban medical diplomacy relate to soft power as a form of international relations and health aid?

EIS Program

• Investigating and responding to public health threats since 1951

Consent and Coercion in Smallpox Eradication

• Coercion can leave behind a residue of resentment that sours public attitudes toward the next vaccination campaign…every new health campaign requires renewed public interest and support, and coercion does not foster continuing public demand.

Reasons to Recognize Coercion

• Coercive tactics lead to increased resistance.
• Power differentials between “aid warriors” and local populations.

Quotations from Stanley Music

• Senior WHO physician-epidemiologist, stationed in Bangladesh

Coercion and Consent Questions

• Is coercion ever justified in global health programs? Why or why not? Under what circumstances?
• In what ways were the problematic actions of EIS officers related to their mandate to eradicate (rather than control) a disease?
• How does this understanding complicate what we know about the International Smallpox Eradication Initiative, and what lessons from it can we take forward into the future?

Atul Gawande

• Harvard faculty, Brigham & Women Surgeon, author of several influential books, and former Assistant Administrator of USAID

Remnick’s Interview with Atul Gawande

• Polls show that [Americans] think that a quarter of our spending goes to foreign aid. In fact, on a budget for our global health work that is less than half the budget of the hospital where I did surgery here in Boston, we reached hundreds of millions of people, with programs that saved lives by the millions. That’s why I describe it as the best job in medicine that people have never heard of. It is at a level of scale I could never imagine experiencing.”

Scope of USAID’s Work

• Bureau for Humanitarian Assistance: FEMA for disasters abroad (earthquakes, famines, conflicts…).
• Global Health Bureau: Works on diseases & health threats, and advances health systems in low- and middle-income countries.
• Bureau for Democracy, Human Rights, & Governance: Focused on international development.

USAID Closure Impacts

• 20 million HIV+ people cut off from ARVs.
• 160k more people will die from malaria annually.
• +1 million deaths due to vaccine-preventable illnesses.
• Staff members left to evacuate homes without assistance.
• Local partners attacked in gang-controlled areas.
• Higher US public awareness & approval of the work of USAID did.

For Next Week

• Readings:
  • B & C, Synopsis & Conceptual Tools for Ethics, Projects, and Human Rights
  • Patel, Treating Depression Where There Are No Mental Health Professionals (p. 424-427)
  • Farmer et al., Structural Violence & Clinical Medicine (p. 324-332)
  • Brown & Closser, Global Health: Your Life, Your Life Decisions, Your Moral Obligations (p. 480-490)
• Section: Informal presentation and discussion of digital media deliverables (note: Friday sections, you will do this tomorrow)
• Digital Media Deliverable due 4/27
• Slack self-assessment due 5/4 – catch up now if you have fallen behind!