What Do We Do When the World is Burning?

In my book, Achieving Access: Professional Movements and the Politics of Health Universalism¹, I show how fierce political competition in Thailand and Brazil led political parties to be more open to the entreaties of “professional movements”² – elite movements of doctors and lawyers, who sought to institutionalize access to healthcare and AIDS treatment on behalf of the people and frequently over the concerns of the broader professions of which they were a part.

By contrast, in South Africa, amid the deep legacies of apartheid, an overwhelming victory in 1994 allowed the African National Congress (ANC) the luxury of being able to ignore calls by professional movements for expansive social policies, like national health insurance and universal access to AIDS treatment. Even today, more than 30 years later, though it is supposedly being implemented, national health insurance continues to be little more than a buzzword than a substantive policy in South Africa, and more than 330,000 South Africans are estimated to have died³ at the hands of the denialist government of Thabo Mbeki.

When I wrote my book (for a brief summary, check out this version⁴ published in the Washington Post), I aimed to make a contribution to our understanding of the politics of social policy in middle income countries. As social scientists, we aim to be keenly aware of and account for the “scope conditions” of our arguments (or the subset of cases to which our theory is relevant), lest we make errors in generalizing the relevance of our findings to other cases where very different political institutions and dynamics predominate.

Whereas fierce political competition enabled professional movements to have such an impact on policy in those countries, here in the United States a recent presidential election that was hotly contested and very close has yielded very different dynamics. The winning party has completely ignored not only scientists and experts, but the interests of its citizens more broadly. Obviously, what is going on in the U.S. right now is not a case of social policy expansion (or the failure of that expansion), as I studied in my book. It is something else entirely.

As I write, the new U.S. government administration has withdrawn from the World Health Organization, has silenced officials at the Centers for Disease Control and even forced them to retract published papers with words like “gender” in them, has shuttered the U.S. Agency for International Development, has frozen spending at the Environmental Protection Agency while appointing industry lobbyists to leadership roles, has sought to destroy higher education by both slashing federal funding and dramatically ramping up the overhead costs that universities must shoulder when receiving federal grants, has removed public data from government websites that provide the public with a measure of transparency and accountability, has targeted vulnerable minorities and undocumented migrants, has fired thousands of workers, and has worked to undermine regulatory institutions that serve the public interests, such as the Consumer Financial Protection Bureau.

At the same time, the administration has granted a billionaire foreign national with rampant conflicts of interest the ability to suggest what funding and departments should be cut and personnel should be let go, while allowing him access to payment systems for the U.S. Treasury and healthcare systems containing sensitive personal information for millions of Americans. This attempt to permanently damage regulatory ability and authority has already had profound effects. While legal challenges wind their way through the courts, Congress has thus far offered no checks to incredible executive overreach.

While the U.S. stands as a story of regulatory capture by private interests, Thailand’s story (as I told it) offered a very different story of “developmental capture”⁵ by publicly minded professions who sought to promote inclusive social policies of benefit to the broad population (for a very different take, see the following debate⁶). What those reformers created offers lessons⁷ even for much richer nations, like the U.S. And when we compare and contrast cases of successful implementation of universal healthcare⁸ with one another, we can learn even more.

Clearly, the current situation in the United States will not be solved by experts and professionals alone, though they may be able to take a number of actions aimed at influencing policymaking within government and strengthening civil society outside of it.

First, global health professionals can help by prevailing upon moderate lawmakers who are open to understanding the consequences that these policies will reap and by translating some of the confusing and complex developments going on into accessible and understandable pieces that help the general public make sense of what is going on, so that they understand why we are alarmed. Not only can we make those pieces available in the media, but we can also seek to move people to action right in our own social networks. When political administrations have it wrong, we have a duty to say so⁹, even when we voted for them.

Second, to get out of the current predicament, we also need mass mobilization. Global health experts concerned about what is taking place in the U.S. can play a role in this and take cues from the climate change movement. Greta Thunberg and others have inspired people across the world to stand up and make their voices heard, putting the problem of climate change in very black and white terms and arguing that our house is quite literally on fire.¹⁰

Although this kind of agenda-setting has not uniformly led to the large-scale global changes that are needed, it has still spurred incredibly important changes by individual governments, as we have seen in places like Denmark¹¹ and Germany.¹² What is more, the potential of some promising energy alternatives, like commercial fusion technology, has even led some right-wing politicians to support green initiatives in places like Virginia.¹³ If viable, these technologies could prove to be a game changer in the fight against climate change and turn feelings of hopelessness into hope.

Third, both experts and Americans more generally can voice their concerns to their Congressional representatives, as I and many others have been doing regularly recently. People – including those working in global health – can also join many of the demonstrations taking place around the country, including those specifically aimed at pushing back against billionaire grift. Experts working in other countries can encourage government officials and business leaders to help their counterparts in the U.S. see value in regulations that both protect the public and help businesses grow.

Fourth, as courts increasingly look to be places where important decisions will be made, experts can bring the knowledge they have to bear on the issues by testifying in hearings and contributing to amicus briefs that help educate the court on particular issues.

Finally, global health experts can contribute to conversations aimed at recalibrating the balance between state and society right now, both in the U.S. and beyond. As federal funding for research dries up in the U.S., universities there have an opportunity to reduce exposure to a hostile U.S. administration by making positions in schools of public health less reliant on “soft money” (external grants that pay for professors’ salary). If the current moment reveals anything, it is that public health jobs should never have been soft money in the first place. The public interest simply cannot be left to the whims of external donors.

Experts can also create new spaces and sources of funding for researchers working on issues of relevance to public health and the broader public interest at their own universities, so that that vital work may continue. These conversations are already happening, but experts working outside the United States should be asking: what can we do to help? And how can we use this moment to contribute to new, more just configurations of learning and work on global health in the Global South and North?¹⁴

It’s easy to feel overwhelmed by all that is going on and to allow darkness to crowd out the light when times are tough. The future, however, is not predetermined. If we don’t give up the fight, another better world still remains imminently possible. But we all have a role to play, and there are actually many things we can do.