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Garrett on Global Health

February 10, 2017

Globalization and the Future of Global Public Goods

For many years, I have warned that what we call global health—along with humanitarianism, climate change mitigation, development, and food programs—was in grave danger. Having hitched their wagons to globalization, broad humanitarian missions—chiefly financed by the U.S. and UK governments and U.S. private interests—were overly vulnerable to political change in the United States and United Kingdom. After the 2008 financial crisis and the subsequent euro crisis, the volume of my warnings increased, as the pool of major donors to such efforts shrank and dependency on the United States and Bill Gates grew. I sent personal letters in 2008 to several leaders of major multinational health organizations, urging them to prepare for catastrophic losses in donor support and a far-right takeover of the U.S. government.


Bono (L) of Irish band U2 and WEF Executive Chairman and founder Klaus Schwab attend the annual meeting of the World Economic Forum (WEF) in Davos, Switzerland January 22, 2016. (Reuters/Ruben Sprich)

That moment has now come.

Globalization, as a concept and as a trade policy, is under siege. The tables have so dramatically turned that China’s Xi Jinping is urging the billionaires of Davos to defend globalization. The United Kingdom is planning for a “hard Brexit” from Europe, if Prime Minister Theresa May has her way. And U.S. President Donald J. Trump has, after three weeks in office, dismantled the Trans-Pacific Partnership, taken first steps to destroy the North American Free Trade Agreement (NAFTA), threatened to impose a 20 percent tax on all goods imported from Mexico and position soldiers on the border, commanded automakers to return all their manufacturing to American soil, vowed to withdraw from multiple treaties including the Paris climate agreement, reinstated and expanded the 1983 Mexico City policy prohibiting overseas financing and discussion of abortion services, and banned travelers from seven Muslim nations from entering the United States. On January 30 at the African Union’s annual summit meeting in Addis Ababa, outgoing chairwoman Nkosazana Dlamini-Zuma took note of Trump’s presidency, telling the AU delegates, “We are entering very turbulent times,” with an American ban on immigration and travel that is, “one of the greatest challenges to our unity and solidarity[1] .”

South African Home Affairs Minister Nkosazana Dlamini-Zuma addresses the media during the leaders meeting at the African Union (AU) in Addis Ababa July 15, 2012. (Reuters/Tiksa Negeri)

Here is the bottom line, which I deliver with a knot in my gut: all global public goods will now face dire, even existential, financial and political threats as they become secondary victims to the general assault on globalization and liberalism.  

Within nations, public goods such as mass transportation, safe drinking water and sewer systems, free education, healthcare, environmental safety, and retirement services thrive or fail based on state revenues and the presence or absence of kleptocracy and corruption (which are estimated to cost the world economy $2 trillion per year). In liberal democracies, the general public—especially the middle classes—may agitate on behalf of reliable public goods, and politicians who fail to provide such services, or who use public projects to fatten their bank accounts, may find themselves voted out of office. A democracy is strongest when an educated, prosperous middle class holds the feet of those in power to the fire. Conversely, democracy is weak when less-educated poor people accept their fate, a middle-class minority is timid, and a small elite rules, with its hands in the national coffers.

The notion of global public goods is quite new. Few global institutions existed before the 1921 creation of the League of Nations, and most of those existing today arose after World War II and during the Cold War. Despite the communist-capitalist divide of the later twentieth century, there was a shared dream among nations and within the UN system to improve the health, education, safety, and survival of all humanity. Developed nations provided public goods such as smallpox eradication and child vaccinations through a chain of multinational organizations, most of which were either part of the Bretton Woods institutions or United Nations, or closely allied with them. There was an implicit conviction that robust public goods served to improve the survival and security of both the needy and donor countries by enhancing political stability and growing global economic markets.

Of course, much of the twentieth-century drive to provide public goods, such as safe havens for war refugees and decent schools for children in poor countries, was built upon previous colonial systems and open to accusations of neocolonialism. The British, in particular, built a nineteenth-century empire that rested on the provision of English-style public goods and services to populations from Jamaica to Bombay Cape Town to the Yukon. It would be a mistake to ignore the colonial foundation upon which globalized public goods rested. Even now, decisions about what books children should read in Lusaka, which vaccines should be delivered to Kathmandu, what sorts of genetically modified crops should be developed for drought-stricken farmers in the Sahel, and what ancient mounds ought to be designated World Heritage Sites are too frequently reached in Berlin, Geneva, London, Oslo, Paris, Rome, Seattle, Stockholm, Tokyo, or Washington.

A 2014 article in the Lancet put the case bluntly, arguing that global health had “become the lapdog of the geopolitically powerful, a foreign policy instrument of hyper-rich nations,” that burnished the reputations of wealthy world universities and foundations while acting as “an instrument for a new era of scientific, programmatic, and policy imperialism. A discipline in which those who claim the right to study, speak, argue, publish, perform, and judge (and whom we now politely call partners) are part of an apparatus of power, self-interest, and control that denies justice and dignity to billions of people worldwide.”

But perhaps a bit of neocolonial arrogance was a small price to pay for the near eradication of polio, the dramatic reduction in number of people living in extreme poverty, and serious surges in both life expectancy and gross domestic product (GDP) in Brazil, China, India, Indonesia, Mexico, and South Africa—countries that are home to 3 billion of the 7.4 billion humans on Earth.

It is perfectly reasonable to now fret whether globalization will be alive and well by 2020, and whether the global public goods that have benefitted from globalization will find new ways to garner international support, or fade alongside. Back in October 2–16, when the outcome of the U.S. election was uncertain, the New York Times editorial board took note of trade tensions and rising nationalistic tendencies around the world, warning that “the year ahead may determine whether the West can overcome its current troubles. A vital lesson of the modern era is that internationalism has stabilized the world, while lapses into bellicose nationalism have wreaked havoc.” They go on to say that “this generation of Western leaders faces the greatest and most consequential test in seventy years.”

Nearly six months later, that challenge has arrived, and nothing less than the survival of globalization is on the line.

The Globalization Challenge

In his letter of resignation as Britain’s chief representative to Europe, Ian Rogers made it clear that he was not willing to serve as the United Kingdom’s arbiter for a tough implementation of Brexit. He warned, “Free trade does not just happen when it is not thwarted by authorities: increasing market access to other markets and consumer choice on our own, depends on the deals, multilateral, plurilateral, and bilateral that we strike, and the terms that we agree.” Failure to embrace mutually agreeable trade and other forms of multinational relations, he continued, would ensure well-distributed social and economic pain.

My CFR colleague, Sebastian Mallaby, writes of a globalization reset, rather than a death knell, but he argues that it is nevertheless a dangerous shift. The world became more mobile as the pace of openness and globalization picked up after the millennium. For example, the number of refugees and economic migrants remained at roughly the same 3 percent of world population level throughout the post–World War II twentieth century, year after year. But beginning in 2005, the number of people on the move swelled steadily, now approaching 3.5 percent of humanity. Because the overall global population has also grown, any incremental increase in the percentage of humanity on the move is a large number of men, women, and children. Mallaby notes that global trade grew slowly, but steadily, from the onset of globalization in the early 1990s until the 2008 financial crisis, after which it plunged, recovered, and is now slowly but steadily declining.

By themselves, neither the political tensions associated with movement of refugees and economic migrants nor the downturn in cross-border trade would severely challenge overall globalization. According to Mallaby, the game-changers are the world’s largest banks, which have responded to the 2008 financial crisis by hoarding cash and drastically reducing lending. To put it bluntly, the spigot on international flow of cash is just about in the off position.

Globalization is making business especially tough for small locally based companies, agricultural growers, and retailers in wealthier countries—sectors typically loan dependent. Not surprisingly, some of the angriest voters in wealthy countries are individuals running small businesses. In the United States, one of the hardest-hit groups is college students, which by the end of 2014, faced a collective debt of $1 trillion in direct loans, interest, and fees. The closed cash spigot also hurts development schemes and emerging industries in middle- and low-income countries. Ultimately, the most competitive nations, able to sail the stormy seas post-2008, are the same victors of capitalism that reigned twenty years ago. Promises of domination by newcomers like Brazil, China, India, and Indonesia remain unfulfilled.


Graphs courtesy of IMF, Finance & Development magazine, December 2016.

By one new estimate, Brexit will result in a 30 percent reduction in average wages in the United Kingdom by 2030. Mallaby’s “reset” for globalization may be an extremely painful transformation.

International Monetary Fund senior economist Ali Alichi argues that the result of these changes to globalization has been a “hollowing out” of middle classes in wealthy countries, especially in the United States. Obtaining loans to cover home improvements, college education, small business expansion, and severe medical expenses has become harder for middle-income earners, and interest rates and penalty fees have risen. Lacking a financial fallback, the middle class is shrinking.

City University of New York economist Branko Milanovic sees this hollowing of middle classes as “the greatest reshuffling of income since the Industrial Revolutions;” it has not only constricted wealth at the top of countries’ elites but also redistributed the geography of the global middle class. In the 1980s, Milanovic says, Asia had almost no perceptible middle class, half the continent’s huge population lived in poverty, and another 40 percent were in economically vulnerable conditions, just one paycheck or bad harvest away from joining the ranks of the impoverished. Meanwhile, in the West, about 60 percent of the population was middle or upper-middle class, and the number of those in poverty was extremely small.

Thanks to globalization, Milanovic argues, the distribution of poverty and wealth in Asia had changed radically by 2011. The poor had dropped to just over 10 percent, 60 percent were now considered vulnerable, and most of the remaining 30 percent had joined the middle, upper-middle, and rich classes. In the West, meanwhile, the middle class shrank by about 5 percent as the wealthier classes grew.

Economist Dani Rodrik asks the obvious question bluntly, “Is global equality the enemy of national equality?” Since 2011, the shift in actual wealth to a tiny minority of global society has hastened. By the end of 2016, eight men (six in the U.S.) collectively possessed half of the planet’s private wealth.

Financial Times economics analyst Martin Wolf argues that the shifts in global wealth, pain among the losers in globalization, and populist reaction against international trade and political openness have spawned an age of “world disorder.” Wolf writes, “We are living, once again, in an era of strident nationalism and xenophobia. The hopes of a brave new world of progress, harmony and democracy, raised by the market opening of the 1980s and the collapse of Soviet communism between 1989 and 1991, have turned into ashes.”

Some observers say that the world is reaching a series of tipping points that could dissolve globalization, enhance nationalism, and send the world order into chaos. CFR President Richard Haass insists in his new book that “chaos” is too strong a word, preferring “disarray,” but he shares the concern that not only global public goods but also all systems of global governance are imperiled. We are headed not to a new world order, as was the case after the fall of the Soviet Union, but into global disorder. The World Economic Forum issued reports this month demonstrating that government and corporate corruption, coupled with rising violence in all forms other than conventional warfare, are costing the world economy more than $13 trillion each year. As global governance weakens, the flow of refugees and migrants rises, middle classes shrink, and nonconventional violence and corruption continue without repercussions, the entire world economy could reach a point where it simply cannot sustain the costs.

A new world poll shows that populaces increasingly want strong, tough leaders, at the expense of global cohesion. Just 40 percent of Americans agreed in the 2017 poll with the statement, “We need a strong leader,” but half the British agree, as did 65 to 70 percent of South Koreans, Italians, and Israelis and fully 80 percent of the French. The strongest pro-populism sentiments (defined as nationalistic, anti-immigrant, and willing to see economic slowdown as a hedge against “foreigners”) were voiced by Americans, French, Hungarians, Israelis, Italians, and Turks.

Trump’s election in the United States seemed, to many observers, to represent a sort of ultimate tipping point toward the world in disarray or, more likely, toward self-interest-driven chaos. In his inaugural address, Trump called upon the nation: “At the bedrock of our politics will be a total allegiance to the United States of America, and through our loyalty to our country, we will rediscover our loyalty to each other.” Right-wing politician Geert Wilders, who may well be the Netherlands’ next prime minister, said the following day, “Yesterday a new America . . . tomorrow a new Europe. We are at the dawn of a patriotic spring.” And at the same gathering of populist groups from across Europe, Marine Le Pen, leader of France’s right-wing National Front, denounced “globalism” and cheered the “return of the nation states.” This echoes Le Pen’s proclamation a year earlier, “Now, the dividing line is not between left and right, but globalists and patriots.” 

The most immediately frightening prospect for conflict in this fractured, trade-blocked world is, according to Wolf, a trade war between the United States and China. A top military leader in China’s People’s Liberation Army told the South China Morning Post that “‘a war within the president’s term’ or ‘war breaking out tonight’ are not just slogans, they are becoming a practical reality.”

Moreover, Trump has managed to antagonize a number of foreign leaders over the course of his first three weeks in power, including China’s Xi, Mexico’s Enrique Peña Nieto, Australia’s Malcolm Turnbull, and Germany’s Angela Merkel. European Council President Donald Tusk, a conservative former premier of Poland, issued a statement on February 8 decrying Trump administration actions and calling for a full European Council debate on the future of relations between Europe and the United States.

On the eve of the World Economic Forum gathering in Davos, many of the richest and most powerful financial and corporate leaders expressed fears about Trump’s leadership, but by the time they gathered three days before the inauguration, most seemed to have changed their tunes. As former Treasury Secretary Larry Summers wrote from the World Economic Forum, “I am disturbed by the spectacle of financiers who . . . three months ago were telling anyone who would listen that they would never do business with a Trump company rushing to praise the new administration.”

The stock market proved Summers’s critique: euphoria about Trump swept across multiple financial sectors driving the Dow Jones average over twenty thousand for the first time in history.

Impact on Health Public Goods in Wealthy Countries

According to Oxford-based OXFAM International, there has been a sharp increase in impoverishment across Europe: “Between 2009 and 2013, the number of Europeans living without enough money to heat their homes or cope with unforeseen expenses, known as ‘severe material deprivation,’ rose by 7.5 million to 50 million people. These are among the 123 million people—almost a quarter of the European Union’s population—at risk of living in poverty, while the continent is home to 342 billionaires.

Since the financial and euro crises, extreme mental health problems, including suicides and violence, have increased across Europe’s hardest hit southern nations. Spain, for example, has 25 percent unemployment, with young working-aged men hardest hit, and suicide and suicidal behavior among those men soared. In Greece, where unemployment hit 27 percent, winter skies filled with dangerous levels of small particulates, as people burned anything they could find to warm their homes. Health budgets have been cut by Greece’s beleaguered government and all manner of public health and medical services have been greatly reduced, rendering care for everything from diabetes to advanced carcinomas less accessible, more costly to patients, and, in many cases, unavailable altogether. Hardest hit have been the elderly in Greece; mortality among eighty to eighty-four-year-olds has jumped 12.5 percent, and those eighty-five and older have witnessed a terrible 24.3 percent increase in mortality. At the other end of life, post-2008 Greece has experienced large increases in maternal, infant, and child mortality.


A rally outside parliament in Athens in June called for the Greek government to agree a deal with its creditors. (REUTERS/Yannis Behrakis).

A leaked International Monetary Fund (IMF) report says Greece faces an “explosive surge” in debt, “Greece cannot grow out of its debt problem,” and without relief from the rest of Europe, Greece’s debt threatens to bring most government programs, including health care, crashing. Within three years, the IMF forecasts, the country’s debt burden will exceed 170 percent of its GDP. While Greece is not in as dire condition as, for example, Venezuela, its hospitals are often bereft of supplies, its physicians and nurses grossly underpaid, and all social safety nets have been slashed.

As dreadful as public goods and health are for the Greeks, conditions for refugees and migrants in the country are far, far worse. In tough economic times, it seems, there is no right to health.

According to the World Health Organization (WHO), the pain of economic despair has been felt in the health of populations all over the world, as evidenced by rising suicide rates in Hong Kong, throughout the Americas, and across Europe. A health survey of post-2008 Europe found the recession damaged medical systems all over the continent, largely because governments constricted public goods spending just when the burden of disease and mental illness skyrocketed in their populations. University College London’s Michael Marmot, who created the concept of social determinants of health, warns that austerity and shrinking middle classes are creating health crises that go far beyond limited access to quality medical care. While “conventional wisdom would focus on more tangible causes of ill health: poor lifestyle choices or lack of access to health care,” Marmot writes, “lack of access to health care is, by and large, not the cause of ill health; it might be the cause of a great deal of unnecessary suffering as a consequence of ill health. Unhealthy lifestyle, smoking, alcohol, diet, and obesity are, of course, implicated in non-communicable disease, along with stress pathways, but we have to ask why increasingly these unhealthy lifestyles follow a social gradient. We have to address the causes of the causes—the social conditions acting through the life course that both affect exposures and people’s behavior.”

Back in 2014, the Lancet–University of Oslo Commission on Global Governance for Health, released a landmark study of the factors pushing and pulling at the morbidity and mortality of humanity. While the report identified many weaknesses in the global governance of health, it found external forces have far more significant influence on human health than medical and public health services. “Although the health sector has a crucial role in addressing health inequalities,” the researchers wrote, “its efforts often come into conflict with powerful global actors in pursuit of other interests such as protection of national security, safeguarding of sovereignty, or economic goals.”

Solving disparities in health access, quality, and Marmot’s notions of social determinants of health, the group concluded, “cannot be addressed within the health sector, by technical measures, or at the national level alone, but require global political solutions.”

In 2017, national leaders may not have an appetite for global political solutions. For fourteen years, the Center for Global Development (CGD) in Washington has compiled the Commitment to Development Index (CDI), scoring Organization for Economic Cooperation and Development (OECD) nations on their direct assistance, financing, technology transfer, security policies, and openness to migration related to poorer countries. Over the first thirteen years, the index saw a steady rate of commitment, with some increases from the Scandinavian nations. Close nation-by-nation scrutiny shows most countries’ rates have flatlined, the newest CDI, covering calendar year 2016, shows commitment has now peaked, compelling the researchers to ask whether commitment to globalization, especially on behalf of the poorer nations of the world, will now decline. They note thatglobal policymaking is at risk, threatening the international liberal order which has, for all its faults and lacunae, served the world well since the second world war.” The latest CDI finds the United Kingdom ranking at number nine and the United States at number twenty out of twenty-seven. The data does not reflect the likely impact of Brexit on UK CDI performance or of the Trump administration in the United States.

Michael Hubler of Leibniz Universitat Hanover in Germany goes further in his worries about the future of foreign aid, arguing that climate change is rapidly harming the services global public goods are meant to address, such as drinking water, agricultural development, and human health. Because of these looming crises, he argues, the sort of stagnant commitment measured in the CDI is actually a substantial downturn. Only with significant, multibillion dollar annual investment in climate mitigation, Hubler insists, can spending on general public goods begin to keep pace.

The World Health Organization Faces the Music

From January 25 to 30, the executive board of the WHO convened in Geneva, with the United States represented by now former Centers for Disease Control and Prevention (CDC) Director Tom Frieden. Back in May 2016, I delineated the challenges facing WHO, and described its new, novel voting process for selecting a director general (DG) to succeed Margaret Chan when her term ends in July. The executive board had a great deal on its agenda, given WHO’s dire financial situation, but the top issue was paring down a list of six declared DG candidates to the three who will—for the first time in WHO history—face a general election at the annual May gathering of the World Health Assembly.

The finalists selected are Sania Nishtar, former Pakistani minister of health; England’s David Nabarro, a career UN official; and Tedros Adhanom Ghebreyesus, who has been both minister of health and foreign minister for Ethiopia. There is not a great deal of daylight between the three candidates in their mission statements or perspectives on WHO’s role in the global health landscape: all profess views well in line with the optimism recently put forth by the Friends of the Global Fight Against AIDS, Tuberculosis, and Malaria. When the WHO member states gather to vote in a secret ballot, one-country-one-vote procedure in May, the result will be a combination of horse-trading, promises, regional alignments, and the characters of the individual representatives.

I would suggest that the two issues of greatest importance to the survival of WHO are its relationships to globalization and to the Trump administration. Both those issues boil down to money: how much will flow into WHO coffers and how will it be spent? It will take a crafty, tough leader to guide WHO through the stormy seas ahead.

Powerful Republicans in the U.S. House of Representatives and officials in the American Chemistry Council (ACC)—the powerful organization representing the likes of Dow Chemical, Monsanto, and Dupont—are already setting their sights on WHO. The manufacturers are more than a little angry with WHO and its International Agency for Research on Cancer (IARC), which designates carcinogens. IARC routinely issues monographs that designate such things as pesticides, food coloring, herbicides, and other chemical products with various risk levels. Chemical manufacturers do not like seeing their products labelled “human carcinogens” and want the IARC either reformed or destroyed. In 2011, the IARC declared cell phones a potential source of brain cancer, creating a firestorm of criticism, though the U.S. National Cancer Institute lent quiet support to IARC’s concern about radio frequency radiation and neurological disorders. The FDA filed IARC’s concerns in its registry, but took no action against the phone industry. For its part, WHO released, retracted, and rereleased statements in a manner that seemed to invite scrutiny and undermine credibility.

The ACC has powerful friends in Congress who vow to hold hearings soon to interrogate the credibility of WHO. The UN agency is vulnerable, in part because IARC operates out of Lyon in a semiautonomous fashion not directly under the DG’s control. And because Chan is leading an organization that is battling its own demons in Geneva and regional offices, including fraud and corruption charges, resistance to reforms, and acute dependency on American money.

In addition, the entire UN system, including WHO, is threatened by Congress and the White House. All recipients of U.S. aid, especially UN organizations, may face audits ordered by the White House. Though the Trump administration has backed off from initial orders to reconsider, or pull out of, every treaty agreement and the UN system, the White House intends to revisit the question later this year.

For WHO and its partner agencies and NGOs, the Trump administration’s immigration limitations have already hurt humanitarian work, slowed collaborative disease research, and limited gatherings of aid workers and scientists. Especially hard-hit are health programs in and around Syria. Depending on which agency’s reckoning is preferred, the travel ban has already resulted in revocation of 60,000 to 100,000 visas. By one figuring, a half million more individuals who have legal U.S. residency documents or visas would be unable to return to America from overseas visits if the Supreme Court rules in favor of Trump’s executive order. It seems certain the executive order will find its way before the Supreme Court, which is currently evenly divided between four liberal and four conservative justices. It is probable that a divided court, unable to rule, would leave the executive order in limbo and the nation in an unprecedented position.

When coupled with Trump’s executive order banning overseas funding or communication related in any way with abortion services—the so-called global gag rule—the mobility of international health workers will be a severe challenge for WHO and all its sister agencies and nongovernmental organizations (NGOs).

If the voters in the World Health Assembly in May can manage to put self-interest aside and make their selections based on commitment to the long-term survival and significance of WHO, they will need to scrutinize the backbones, negotiating skills, diplomatic feats, and fundraising histories of the final three candidates and opt for someone capable of extracting cash from Bill Gates and Theresa May and standing up against assaults from the U.S. political leadership. A smart DG can hire top-flight managers to handle secretariat affairs and steer internal reforms so the DG can focus on fighting the powerful interests attacking globalization and global health.

Losing the Security Dimension of Health

When the Zika outbreak occurred in 2015, Congress turned away from its previously bipartisan concern about health security, which had been a priority since the Clinton administration formally elevated emerging diseases, HIV, and influenza pandemics to the status of national security threats. What was most astounding about Zika, from a policy perspective, was the breakdown in this de facto pact among the Washington leadership. For the first time since the Reagan administration stifled HIV/AIDS research funding, Republicans in the House and Senate were willing to hold up funding for research and control for eight months in a partisan dispute with President Barack Obama. The issues underlying the divide had nothing directly to do with the Zika virus or Aedes aegypti mosquitoes, babies born with microcephaly, or adults suffering temporary paralysis. It caused by was a battle of wills with Planned Parenthood, with the Dixie flag thrown in for good measure.

The CDC’s Tom Frieden and Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases, were not helped in their fight on Capitol Hill by WHO’s decision to drop Zika from global emergency status. Republicans heaved a collective sigh of relief; their failure to act seemed vindicated by a miraculous viral retreat. Of course Zika had not disappeared—only the sense of emergency had done so.

Susan Rice, the outgoing president’s national security advisor, gave an interview to PBS host Charlie Rose two days before Trump’s inauguration, in which Rose asked, “What’s your biggest nightmare?”

“A pandemic flu, frankly, is a major concern,” Rice responded. “We have threats that we knew of in 2008, but they could arise at any moment like pandemic flu, which we’ve also discussed. That’s not new, but is persistent and the risk remains.”

“How serious do you see that?” Rose asked Rice.

“I think it's a real risk,” Rice said. “It's a fact. It will happen.” She outlined the Obama administration’s efforts to prepare for such a pandemic. She explained, “We have called this the global health security agenda and we got fifty countries or so that are actively part of this. And that’s the kind of long-term effort that we’re going to need to build and sustain around the world to diminish the risk of pandemic, but we’re not going to eliminate it.”

However, a National Security Council dominated by Steve Bannon and Trump’s team seems unlikely to maintain the global health security agenda, linked as it is to Obama and to globalization.

Under Bannon’s leadership, Breitbart News published stories claiming that all major infectious diseases were brought to the United States by immigrants, that the German health system was collapsing under the weight of rare diseases brought by refugees, that Syrian refugees spread “flesh-eating disease,” that birth control makes women ugly, that WHO “discovered” that transgender conversion causes deadly diseases, and that so-called fat-shaming is the best path to weight loss, among other such stories typically found in the types of tabloids that claim Elvis is alive.

The health security agenda may now either be dead in the U.S. government or be used as another bludgeon to hammer immigrants, refugees, and Mexicans.    

Closing Hope

In his inauguration address, President Trump repeated, “America first,” calling for patriotism and nationalism in the United States. Within hours, a Dutch comedy show, Zondag met Lubach, aired its response, “The Netherlands Second.” Not to be outdone, late-night comedy shows across Europe aired their own pleas to make their nations second—or, in the case of Lithuania, third. The idea, well, globalized as videos from Morocco to the German coastal region of Ostfriesland vied to be number two in the world. And on the home front, the ratings for Saturday Night Live have increased 22 percent compared to last year. The more Trump tweets criticism of the show, the larger its audience becomes. And around the world cartoonists are having fun at Trump’s expense.

Globalization in trade and politics may be in trouble, but on comedy shows it seems to be thriving.

Laurie Garrett
Senior Fellow for Global Health
Council on Foreign Relations