By Michelle Morse, MD, MPH | Contributing Editor for Global Health
Over the past thirty years, American medicine has witnessed an unprecedented expansion in global health engagement amongst its trainees and faculty, partially, if not largely, fueled by the health care injustices lived so dramatically by patients in resource-limited countries around the world during the HIV/AIDS epidemic. Initially seen as disruptive, the interventions in the health sectors of Global South countries by American health professionals were eventually accepted as essential acts in the movement towards achieving global health equity. As America experiences the Trump era, endless questions have arisen amongst global health professionals about the implications of Trump’s “America first” platform on global health. Will Trump’s nationalist agenda eliminate funding for life-saving global health programs, cause progressive health professionals engaged in global health to make a reactionary turn towards the fire at home, and even force global health practitioners to more closely examine their own prejudices?
It is no secret that American physicians leading the guard in global health tend to be part of the political left. Global health tends to attract left leaning physicians because of the global health movement’s belief that every human being has a right to receive high quality health care. Asserting that Global North countries have a responsibility to contribute towards strengthening health care systems in the Global South (a redistribution of resources, of sorts), global health offers the opportunity to practically address urgent health care access inequities in the Global South. Considering these principles, global health professionals like myself are deeply frustrated by the Trump administration’s efforts to repeal the Affordable Care Act and cut global health spending at USAID and other similar programs. Though many of us are rightfully drawn towards activism in the USA to resist these moves by the new administration, I worry that the health and health systems of the Global South will suffer if the majority of global health professionals shift to focus domestically without continuing their engagement in global health.
While some would say that the current neoliberal structure of development aid is already ineffective, especially since so many of the aid resources are actually directed back to the country where the aid comes from, what would it mean if global health funding was eliminated, and American global health professionals suddenly focused exclusively on domestic health? Would it allow Global South countries to assume stronger leadership, decision-making, and self-directed problem solving? Or would it mean that Global South communities would be even more deprived of much needed resources and health care access? Post-earthquake Haiti, where I have worked for seven years and lived for two of those years, is one compelling example of both the peril and the potential of aid. Of the $8 billion US funds provided in aid after the earthquake, less than 1% went to the Haitian government who was ultimately responsible for rebuilding the country. Yet, as appalling as this statistic is, it does not adequately describe the individual impact of short- and long-term global health engagement by American health professionals in response to the earthquake. Take EqualHealth for example, the organization I co-founded. EqualHealth is a non-governmental organization focused on bringing light to the socially determined root causes of illness and creating equity in opportunity for Haitian health professionals whose talent and vision are often overshadowed by negative media narratives about Haiti, weaknesses in the Haitian public health system, and limited opportunities for professional development. All things considered, the reality is that countries like Haiti rely on the shrinking aid from global health programs such as PEPFAR to keep their health systems running despite fluctuations in attention from the donor world. Where Global South countries would find themselves without USAID, or partnership with Global North health professionals, or other mechanisms to ensure more adequate resources for pressing health concerns is as predictable as where Americans, who rely on the Affordable Care Act for health insurance, will find themselves when it is repealed and replaced with a market-based solution.
— USAID Global Health (@USAIDGH) May 16, 2017
What I have witnessed in my academic institution is an exciting and growing interest amongst trainees in building infrastructure to resist the new administration’s domestic health care and civil rights policies. To mount a harmonized response, they are looking into establishing indivisible chapters and partnerships with community based organizations, learning and using direct action methods such as bird-dogging, non-violent protest, and holding teach-ins on community organizing. These are often the very same trainees that are also interested in global health. Though many of them are considering careers in global health, opportunities for long-term global health engagement with clear career paths and mentorship are often limited, and may now become even more limited given the policies of the new American administration. On the other hand, recent significant increases in donations to organizations like Planned Parenthood could mean new opportunities for engagement for these trainees, shaping careers focused on domestic health care. This is occurring at a time when structural competency and social medicine are emerging as key areas of focus in medical school and residency curricula, and trainees are being encouraged to engage in activism as a professional obligation rather than aspiration. Health professionals often hesitated to engage in activism as it was not an explicit part of their training, and opportunities to act were difficult to identify, but these barriers seem to be evaporating under the new administration.
In response to mounting evidence documenting how health care provider prejudice impacts health, American medical schools are also developing competencies in which trainees and faculty alike are encouraged to reflect on their personal biases. These competencies are even more relevant now as the policies of this new administration threaten the rights and livelihoods of people of color, women, Muslims, and immigrants. Efforts to establish global health competencies, while laudable, have often been silent on addressing the issues of racism, sexism, and other forms of prejudice amongst global health professionals. The social and cultural power and privilege clash that occurs when predominantly white global health professionals from Global North countries descend on countries in the Global South to work hand in hand with local health professionals who are predominantly people of color is a tinderbox for racism and prejudice in all its forms. The global health movement can learn from the new light being shed on the old problem of racism, as a result of the racist policies and messages coming from the Trump administration in its first 100 days. The global health movement needs to take the necessary steps to explicitly address racism and other forms of prejudice amongst its members, and ask honest questions about why more Americans of color are not currently a part of it. The far too common assumption that being left leaning, progressive, or engaged in global health is incompatible with being racist is simply incorrect.
As communities and countries in the Global South continue to suffer the consequences of neoliberalism-induced fragile health systems, some global health professionals may decide to deepen their engagement outside the USA, attempting to flee the nationalist, racist, and sexist trends of the new administration by moving and working abroad. Other global health professionals may decide to engage domestically to resist the actions of the new administration, seeing the battle for health care access and civil rights at home as more urgent and compelling. Ideally, all progressive global health professionals, whether choosing a domestic or globally focused path, will begin to address their own prejudices in new action-oriented ways.
There is a delicate but important balance between advocating for ongoing American engagement in addressing global health inequities, while also addressing domestic health care threats. One shouldn’t be prioritized over the other or at the expense of the other, as they represent two parts of the same global battle for health as a human right that culminated in the Alma Ata Declaration, lost its way, and is reemerging. Perhaps the real test will lie in America’s response under the Trump administration to the next Ebola, the next Zika, or the next HIV/AIDS epidemic.