US health under Trump, gender justice, and child mortality

Gavin, Richard, and Jessamy reunite for another bonus episode, covering the first three months or so of health in the US under Trump. What do the appointments tell us about the administration's agenda? How can institutions stand up to cuts and intimidation? 

We also look at gender justice in global health as laid out by the excellent new Commission in The Lancet, and highlight that the world's impressive gains on maternal and newborn mortality are slowing - what more needs to be done?

You can read "Achieving gender justice for global health equity: the Lancet Commission on gender and global health" here:

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(25)00488-X/fulltext?dgcid=buzzsprout_tlv_podcast_lancetgenderhealth25_lancet

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Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Gavin: Hello, welcome to the Lancet Voice. It's April, 2025. I'm Gavin Cleaver, and today for another bonus episode, I'm joined once again by Richard Horton and Jessamy Bagenal. It's been a couple of months since our last discussion, but today we're gonna be talking about some pressing issues, including the recent appointments in the US Health Administration, their impact on health in the US and across the world.

And we'll also talk about the importance of gender justice following the recent Lancet Commission on the topic, as well as the slowing progress on child and maternal mortality. So thanks very much for joining us. Let's dive in.

Alright, Richard Jessamy, welcome. Welcome back. It's been a few months since our last one. We are in the new and improved Lancet offices. 

Richard: Smaller but even more beautiful. Yep. Yes. Refined. 

Jessamy: Yes. Just like us distilled. 

Gavin: Exactly. Exactly. And there's a, I've 

Richard: lost eight kilograms since we last did one of these.

I would 

Jessamy: say that's probably at least the fifth time you've told me that. I, but I haven't. I haven't. And I'm so pleased that you're pleased about, I haven't said 

Richard: it on the podcast and it's, 

Gavin: it's the first time I've heard it as well. Yes. But that's probably, I've not you in a couple of months I've also said about 

Jessamy: the plan to keep it at that.

Richard: Exactly. No, exactly. Very good. I had a bout of pneumonia. Oh, I'm sorry to hear that. And thanks to the. Administration of Azithromycin and CCL from the wonderful University college hospital here in London. I made a rapid, not so rapid rec recovery and lay about for two weeks and managed to get myself back to a fighting weight.

So I'm totally happy in a 

Jessamy: new class about 

Richard: it. Yes, exactly. Who needs. Ozempic, 

Gavin: it's probably preferable to pneumonia, isn't it? I 

Richard: wouldn't prescribe pneumonia as a treatment for weight loss, but it did the job, so I'm very happy, 

Gavin: right? Talking of things that shouldn't be prescribed for things. There's a new administration in the US apparently.

There's a new health secretary, Bobby indeed, Bobby Kennedy. And there's quite a lot to talk about on the health front in the us. So if you'd like to kick us off what's been your highlight of the first three months of the Trump and Kennedy administration? 

Richard: I think the shock that a country, I.

With such a stellar record in science and medicine, could appoint a man to be Secretary of Health and Human Services, who has absolutely zero qualifications for the job indeed. His qualifications militate against his appointment. To see a country do that and all the associated appointments actually which make one deeply worried about the future, I.

For the us the appointment of Jay Beria to be head of the NIH, the man who co-signed the Great Barrington Declaration. That piece of magnificent public health advice that thankfully was shredded the moment it was published, but nevertheless helped to stimulate. An abreaction amongst the American public to sound public health advice coming from more sensible voices.

There's a coie of individuals who President Trump has appointed into senior health and scientific positions that mean the next four years is going to see a recession in terms of the scientific leadership provided by. What should be regarded as a science superpower? That's not just bad for America, it's bad for all of us, partly because scientific leadership coming from the United States has a huge impact on other countries, but also just the simple material effect the cutbacks to indirect costs at universities if they fully go through.

The cutting of U-S-A-I-D we're going to see domestically and internationally. We are seeing domestically and internationally what is nothing less than a catastrophe for science and health. And it's no exaggeration to say that children. And individuals in low income settings are now dying because of the policies implemented by the Trump administration.

And it was actually Frederick Engles who wrote in his condition. Conditions of the working class in the 19th century that when an individual or a government takes a decision that it knowingly, understands will lead to the deaths of individuals that's social murder. And we are seeing an American administration that is guilty of social murder.

How long have you waiting to pull ENGs out? 

Gavin: Feel like you've had that one for a while. We discussed, didn't we? With with Gavin Ami a couple of months ago on the podcast about. The the global health implications of some of the some of the executive orders so far, and the, what was Elon Musk said, feeding USAID into the wood chipper, for example, is literally already going to result in deaths around the world.

People living in eviscerated conditions compared to where they were before. It's. It's simply unnecessary. The, it does seem as well from the actions of the UK government since then that the necessation of the rise in defense budgets around Europe is go, the first casualty is going to be international aid more generally.

So that's not just an American action either. That's seems to have set a tone where we all become more isolationists, more inward looking and. Abandoned quite a lot of what we've committed to around the world in the name of furthering humanity, in the name of helping everyone to live better lives.

I think it's quite devastating. But then when you look as well upon the, a lot of the issues you laid out there committed against the American people, not just global health. Absolutely. It's quite frightening. The cuts are going to make a lot of people live worse lives. And as Fredic annual was getting at, that's not really what governments were meant to do.

Jessamy: But I think we also have to acknowledge there are a lot of people in the us I was on a call even yesterday with some US authors who, remain surprised that friends and family who have supported Trump are not turning away from these policies are actually, a lot of them remain engaged with it and supportive of it and that is.

A really hard pill to swallow. But I think does point towards the fact that we have to engage with these underlying issues of why people have. Voted for Trump. Why they've why they've taken this approach and why they think that this approach is the right one because the actual, what they're doing are responding to real issues.

We might totally disagree with that response, but I think there would be a lot of people that would argue that lots of people on the center, progressive left have not engaged with those issues in a meaningful enough way. And responded in it. I don't know. Do you? 

Richard: Yeah. No, the domestically, there is something inherently appealing about an America first.

Mindset, especially if your local community has been de-industrialized. There are no jobs. The schools aren't very good. There's no decent healthcare. The environment's not particularly enticing. Yeah. It's not surprising that becomes a constituency for an America first agenda. And indeed, the papers we published in December in our American theme issue.

Ironically now called the Presidential Briefing Book. They set out Yeah. Just how serious that has been. So in one and in one respect, one has to I watched the. Senate confirmation hearings for Robert F. Kennedy Jr. And he said that America is a sinking ship in terms of its health.

And he is right. Absolutely he is right. If you look at those papers we published from adolescent overweight and obesity to loss of life expectancy gains to the massive disparities between d different ethnic minorities. America is a mess when it comes to health. There are multiple crises that have to be addressed.

It's just that this administration, I don't think is the administration to address them. But you're absolutely right. The inattention to these issues by past administrations, both Republican and Democrats has led to this situation. It is entirely rational from that point of view.

It's just that the administration or the president Trump in the election laid out a false prospectus about what he was doing and we are meeting today in the middle of a. Trade war, a global trade war as America and China duke it out. That's going to leave Americans facing rising cost of living higher inflation, higher unemployment.

The very constituencies that voted for Donald Trump are actually going to be harmed the most by, by the trade war. It, 

Jessamy: and similarly from a health point of view, if, Medicaid does get the cuts that they're hoping to pursue. Then, that has a particular impact on rural people living in rural communities who don't have access to hospitals or have long-term disabilities and can't cover their care.

So 

Richard: it feels a bit despairing. And I was talking with a friend of mine Sunday evening and. She works in the field of sexual reproductive health and rights, and she's an American and she's led NGOs in America on sexual and reproductive rights. Worked in the arena for 30 years, and of course she's expressing her despair and I asked her.

So what do we do? And that's where there is an enormous silence. Exactly. Because there were these standing up for science marches in Washington DC Fantastic. But what's the ask? What's actu how, and I. I I asked her, so how are you gonna mobilize, how is civil society going to link with academia, link with the health professions link with others to provide some front of resistance or activism against this?

My, my feeling is that we need to almost take, we do need to take a leaf out of the early eighties with the AIDS movement. We need an act up. For health and science against the Trump administration. That's to say we need to create a very vigorous and activist doesn't even come close. If you think back to what Act Up used to do I mean they were in your face.

In terms of government, that's what we need to do If we're going to get, the administration to at least take notice and the administration's more complicated than people think. If you, if I just look in the global health arena, Marco Rubio, who seems quite happy to roll over on U-S-A-I-D cuts, but you look back at his past voting positions, he's been a staunch supporter of global health initiatives, always voted for the Global Fund, been a supporter of pepfar, and yet.

Rolled over on this buckled capitulated entirely on, on, on U-S-A-I-D, but there are people in the administration who are more rational than others and who would I think be. With the right level of activism, they would listen, especially if they realized that it was electorally damaging for them.

Gavin: But I think compared to the first Trump administration, we're more clinging to that hope rather than, the first administration, the Trump that came in had more of a respect for the political office that he was occupying, was surrounded by, should we call 'em the grownups in the room, the more kind of center right.

Long-term careerist Republicans and now. Bobby Kennedy is a perfect example of the sorts of completely unqualified people that he's brought in to lead major arms of the US government. There are people in there across the current administration that might be able to restrain Trump's worst instinct slightly, but it's nothing like the first administration.

The gloves are off this time around, it feels 

Richard: Yes, it does feel like the Glo, the gloves could be off. But I asked my friend on Sunday, so where, remember all the women protesting in Washington dc they're not there anymore. It's almost like people have people given up. They know that it's not gonna work.

The activism is falling on dead ears, Steve Bannon's agenda's won. It, it does feel a little bit like, we've gotta really organize and I'm not seeing that organization at the moment. 

Jessamy: I think that's right, but then I suppose we get into the sort of conversations about authoritarianism and fascism and where we are because there is a chilling effect.

And when you are arresting, we've had when people are international editors, academics are unwilling to travel to the US because they are frightened domestically, therefore. People are scared, people are frightened. And the unpredictability of the administration, the fact that essentially anybody seems to be able to get arrested and held for whatever reason, these are all tactics and tools of a chilling effect to prevent that kind of activism.

Richard: That's where my additional disappointment kicks in regarding universities. I completely understand that if you've got 400 million threatened from take, taking away from your. Income. You might reflect on what your policies are, but do you really want to close one of your departments your Middle Eastern department in genuflection to the administration's threats?

Apparently yes, American universities are prepared to do that. There's a long and honorable tradition going back to the 1950s and sixties of American universities being a line of resistance against government repression and corruption. What we see now is that universities have evolved into corporations and businesses that seem to have the same values as the private sector.

And so the university values that were different, defending academic freedom, they seem to have gone up in flames. So that capitulation is also quite shocking and one hasn't seen and especially coming from such luminous institutions as Columbia. So it'd be very interesting to watch what other universities do in the face of this.

Gavin: I think what just mentioned is very important though the serious intimidation tactics used by the Trump government. The perfect example being the student that wrote the editorial supporting Palestine and a university magazine and had a residency revoked and was shipped off to a prison somewhere. I think those tactics are very serious.

They're the way that authoritarian governments crack down on this sort of protest. It's got very strong echoes of Orban or Duan in Hungary and Turkey respectively. But it should be said against that background, there were 5 million people out on the streets on Saturday. It just wasn't widely reported on because I think another issue that we have is that there are currently.

Some very different media ecosystems out there. And one of the things that's really been concerning to me is how the kind of long history of which media bodies have access to the White House has been upended over the last couple of months. You've seen these Associated Press get kicked out, for goodness sakes.

That's like them and Reuters, are the two down the middle center report it like it is, and they've been replaced by things like the One American News Network. Who are now firing questions at the president of Ukraine in the White House, for example. So that's an extremely serious situation because we were talking before about.

How do you get this message across about the damage that the Trump policies are doing around the world, the damage they're doing to the health of the people in the us? Actually that's almost impossible unless you find a way to go into this media ecosystem and the situation becomes so serious that either these people have the people accessing that different media ecosystem have no option but to listen, or you can find some way to reach them across that barrier that's been put in place that is essentially a kind of functioning state media.

Richard: Yes it feels like the New York Times is the only line of resistance at the moment. In our little world, our little corner of the world in health and medical science, one of the areas that feels very anxiety provoking is the self-censorship. The fact that people don't want to go on the record, won't go on the record to express criticism because of fear of what it will do.

Again, I read a piece yesterday that was submitted. An absolutely brilliant piece of writing about one domain of health, which is in crisis. And the author, who is extremely well known and I think could easily resist any criticism. Wanted the piece to be anonymous. Because he, it's your point, Justin.

He. Is fearful of what the reaction will be. And yet this person isn't just a domestic leader, he's an international leader in his field. But that's the climate that has been created 

Jessamy: and extremely rapidly. And as we were saying, Richard, all of these conversations that we had before Trump got elected about the strength of American institutions being able to protect against these types of moves and being able to maintain some kind of a resistance when everything has been commercialized, that's very difficult.

Richard: It's just to strike a note of optimism. If I may, I'm old enough to remember America under George Bush. The second, and I remember the election when it was Obama versus McCain, and, that was a very tough time. America did not have a good global reputation post the Iraq war. It felt that this was, this.

Upstart Senator against the war veteran and from the same party as George Bush. And yet literally overnight America pivoted from a country in pretty much despair to a country. Of hope and possibility of self correction. And that's the amazing thing about American democracy that we don't quite have in the United Kingdom.

The country can is sufficiently agile that it can literally change its personality, its political personality with an election and completely transform the way people feel about the possibility for a country i, I feel, yes, two years to the midterms, two years after that, but, we sh this is not forever.

This will change. And in a sense, what we have to do as a health and medical community is do our best to protect the areas that are really fundamental so that in four years time they have survived and they provide the foundation to build upon. But it's I think we have to recognize that if you look at countries that have made severe cuts.

Things don't just go back to normal. When governments change, look at the UK as an example. We hit 0.7% of G nni for development support, and then it was cut by the conservatives and the labor government currently is not just maintaining the conservative cut, but channeling that money.

Some of that money now into as you pointed out, Gavin, greater defense spending it's. Nothing is forever, but it will be less. 

Jessamy: It will be less. And also, I was talking to my mom about this 'cause she's a hit with us at the moment and she was saying, for your generation you were brought up on American TV and culture, friends and all the rest of it.

She was like, I wasn't, I didn't think that America was the center of the world. And for the most part, it wasn't a particularly banal force in my life. It was, a negative force. There were. A country that had values that felt very different to European values of, the death penalty of being very all of these things.

I guess she might 

Richard: have been the Vietnam generation as well. Yeah, she was. Exactly. 

Jessamy: And I thought that was interesting. And I think, her point really was, this is awful. People are gonna lose their lives, their livelihoods. It's an awful waste and it's devastating and a total waste of time and suffering and affliction and energy, but.

Maybe it's a case, but people will work around it. And I wonder to what extent that will happen. We're seeing that happen in the economic space, that people are starting to work around this. They're starting to make new collaborations, and America has been such a scientific superpower. I, and I don't know, are we starting to see health and scientific collaborations refocusing their efforts?

Richard: I'd like to think, but if you've cut literally billions Yeah. From the research budget, you've destroyed 90% of U-S-A-I-D grants. You've made over 2 million children. They don't get food aid for severe acute malnutrition. You don't have a lot to play with. And who, what's gonna step into that void?

Yeah. And Europe's not gonna step up. China's not gonna step up. So this is a gap. Yeah. And it's a gap that won't be filled. Therefore, what is, yeah, I'd like to think that people will reassemble and repurpose what they're doing. But if you've got nothing there, there's nothing to Yeah.

Repurpose. Yeah. 

Gavin: I think why you said Sesame speaks a lot to the soft power the US has developed over the last few decades. You're talking about, you know how our generation consumes largely American music. American tv. Yeah. American tv. It's amazing that the US would, in the space of three months managed to essentially blow that up.

Yeah. Being the world's reserve currency manage exporting so much culture around the world. 

Jessamy: Yeah. And that the values that they were. You know that they were having a positive influence on many societal values that were being, that were progressive, that were about inclusion, that it had, diverse voices that supported gay marriage.

That, and I might, I appreciate these are on the coastal areas and they might not be representative of the center, but they still felt. That they were leading the way in some of those things. 

Gavin: Is there anything else that stood out to you about the Trump administration, Richard? 

Richard: I think that leads us on quite nicely to thinking about our Gender and Health commission that just launched because on January the 20th, one of the first executive orders that Trump signed was around gender, and it was his identification.

His target was this idea of. Gender ideology. And he had, he attacked what he called this gender extremism. And he was going to use his executive order to erase this pervasive ideology that he had, in his view had been polluting the American public sphere. The commission that we, by. Pure luck, if I may just say, we published this week, looks in detail at the anti gender movements that have been building, not just under President Trump, but over many years.

And tries to set out why gender is so important for health, and it's worth just having a, I think it's worth having a discussion about that because what we're seeing is the US mounting this leading now the world's anti gender movement and this is not. An issue. That's some sort of minor philosophical debate.

It's actually central to health. And we need to move this discussion into the health domain, and that's what this commission does. So effectively we're talking about power and the power of women. And also, and this commission doesn't just look at women, it's also looking at trans communities, and it's also looking at the role of men as well.

But the issue of power, how it's distributed the history of that distribution of power, the politics of that distribution of power and the way that we need to think about how we redistribute that power. And in the time of this, growing anti gender movement, the health community provides a very important voice to try and resist that movement.

Gavin: I think it's super important. It's incredible how much of the public conversation has been captured. I. By discussion over gender and a particularly a backlash towards what you were referring to, the amount of hatred opium thrown in the direction of the trans community is quite astonishing to me in political terms.

It's only a very small group of people, but it's come to dominate so much of the political conversation that it is a great opportunity to move it back to health, as you were saying. But 

Richard: I think. This is where taking this wider political view is helpful to, to see how we've got here.

Gender has been weaponized by certain factions in society with certain views about what is the definition of a traditional family, for example. And we should. We should call it out. It is some very conservative religious views. The Catholic Church has particularly led in this, and I've seen it firsthand.

I. In, in Health. Some years ago I was involved in producing a document on children's rights where gender was a very important part of that because of issues around child mar marriage, female genital cutting, and so on. And we presented this document, which was linking health and human rights to the Human Rights Council.

And I thought it would be a slam dunk that everybody would support it. And the only two groups who resisted it, so we, we didn't get it through, was the representative from the Vatican and the representatives from Arab countries, unfortunately and. The argument was that this was, that giving children rights and especially giving young girls rights undermines the authority of the family.

And the family has to take priority over the individual. And if that's your philosophy, then. You've basically got no chance in protecting girls and young women who are under threat. So that's the sort of, yeah, it's that's where I think this what's so good about this commission in thinking about gender justice, this is why you have to take a historical and political perspective.

Otherwise you miss the real diagnosis. 

Jessamy: I think that's right, and for me, I think this commission represents its very powerful rebuttal to a sort of Trumpian set of values, which is to say. The US is a total, state health in the US is a state and the reason that is, is because we've been focusing too much on DEI and too much on gender and this commission.

So completely and absolutely rebukes that and demonstrates that actually, for some of these major preventive causes of death, like smoking and alcohol. None of the policies that we've been implementing take any kind of consideration of gender. They don't have, they're not sex or gender disaggregated.

They're not thinking about how we can prevent smoking in women and men and have different approaches. They're just taking a very blanket approach. And so this kind of capture and weaponization of gender has meant that we haven't really been able to think about it in a scientific way. In the way that we should.

And I think the commission lays that out very clearly and is a great response to this sort of Trumpian narrative that somehow gender and DEI is why everything hasn't been working recently. 

Richard: And I think we also as we get on our high horse and criticize everybody else, we need to hold a mirror up to ourselves.

Because in, so I include the Lancet in all of this. Although I think we do better in some areas than others, but medicine and science, if you look at careers, if you look at pay, if you look at people who occupy leadership positions, think back to Afer Ginsburg Women in Cancer Commission from a year or so ago.

I. There are massive gender inequities, which we have not addressed in our own back backyard. And you do not hear leaders talking about it. Still certainly in the United Kingdom. The leadership of many of our royal colleges and our scientific societies, it's a cabal of men. It's a club and it's a club of people who've gone to a certain type of school, a certain type of university certain medical schools, and.

Others are locked outta that environment. It, it is quite astonishing how that culture is still pervasive in 2025, and I cannot believe that the United Kingdom is the only country like that. 

Jessamy: No, I think it's very similar everywhere and I think, that's why we're in this sort of strange, paradoxical situation where approaches and conversations that were aimed at dismantling that system for the better are now being scapegoated for being the problem.

And it's a sort of, so things were 

Richard: bad before, but now they're even worse because you can't even raise these issues anymore. Absolutely. 

Gavin: Absolutely. But Richard, you mentioned child health at the start of this, and I think you also wanted to talk about R-M-N-C-A-H, which stands for our listeners, stands for Reproductive Maternal Newborn Child and Adolescent Health.

Richard: I, this is where I think, again, there's a link because and it's important. One of the most I think probably the most spectacular success story over the last 25 years has been the halving of child mortality. It's stunning to, to imagine that we've gone from. 10 million preventable child deaths to now 4.8 million preventable child deaths.

It was just a few days ago that UNICEF and WHO issued the latest data for 2024 on child mortality. And that 4.8 million figure, although it's way, way too high the fact that we halved it. Amazing. An incredible health success story. Incredible health success story. But, and this is a big, but the pace of that spectacular success has dramatically slowed down in the last few years.

It's almost halved. In fact, if you look at the annual rate of reduction in under five mortality, it's now 42%. Less in the SDG era than it was in the MDG era. So why is that the political will isn't there? The money isn't there. We've moved on to other more fashionable issues in global health. But the reality is that we've taken our foot off the accelerator of reducing child mortality.

It's very interesting actually, if you look at newborn mortality, because through. Population growth principally. There are some countries where you're actually seeing the numbers of newborn deaths increase, not decrease. If you look at the Democratic Republic of Congo, for example the number of newborn deaths there has gone up from 88,000 to over 110,000.

So while we're doing very well. In terms of rates of mortality in numbers, sometimes, especially for newborns, we're really not doing well at all. So why? How does this link with the issue about gender? Because many of the determinants of child health rest. With the way gender is structured in society, risk factors for premature preventable childhood death, maternal education birth spacing age at which you have your.

Age of which you have your first child, the number of children you have, and this is all about the power of the woman to decide and to have agency autonomy about the decisions they make in their life. And when they don't have that power and autonomy, child mortality goes up. A gendered approach.

Thinking about this phrase that Sarah Hawkes and her team used, this idea of gender justice, again, the way it's portrayed often in the media is this sort of esoteric, theoretical, completely irrelevant issue that just activates a group of extreme feminists. Actually no, it's central. To the way you think about health and in this particular case, child mortality.

Jessamy: And in fact, the gender commission starts, doesn't it? On page three, it says 56% of women, which is moves to 38% of women in Sub-Saharan Africa report that they can make their own decisions about sexual relations, contraceptive use, and the use of reproductive health services. So even globally, with only just over half of women are able to make those decisions for themselves.

Richard: Which is astonishing. Again. 2025. 2025. Astonishing. 

Jessamy: It's an astonishing figure. But Richard, for people who don't live and breathe global health, just give us a little bit of background about this concept of R-M-N-C-A-H because it was set up for a very specific purpose in a very specific time period of the MDGs.

Richard: If you go, if you rewind back to the early two thousands there were NGOs that focused on child survival. That focused on maternal mortality. And that focused on reproductive health. These different groups competed with each other and often loathed each other. And I remember sitting in rooms where the maternal mortality advocates would literally have nothing to do and look with venomous rage and hatred at the child survival protagonist and vice versa.

And the HIV. Advocates the child Survival people didn't wanna have anything to do with the HIV folks because they saw the HIV community as stealing all the money that they should have had. It was like children in the playground. In fact, that's a, that's unfair to children in the playground.

When we had the MDGs, you had MDG four on child survival, MDG five on maternal mortality and reproductive health. And the politics forced them to have to get together. And we had our first series on child survival in 2003, then Newborn Survival a year or so later with Joy Lo. And what you saw was that they re, they came to realize that by combining their forces so that.

You created this concept of a continuum of care. They could actually the sum of the parts would be greater than the individual elements of that sum. And indeed that was true. And as, and we played a small part in it, I think but many, it was a success of many organizations, un NGOs, universities, governments.

As the evidence assembled that there were interventions that would guarantee reductions in mortality. Then you saw political leaders start to say, okay, I can support this because this was not aid money that was going on. Health systems, in other words, being tipped down a drain they could guarantee that.

By investing in vaccines or investing in antibiotics, or investing in bed nets, this would. Yield results. And so you saw Banky Moon launches every woman, every child initiative first Un Secretary General to have a health initiative. You saw the birth of Gavi, you saw the birth of the Global Fund and.

As a result, literally tens of billions of dollars came flowing in where non existed before you saw high level political leaders, even though he was an ultra conservative. I have to give praise to Stephen Harper, prime Minister of Canada, who led on this yen Stoltenberg from Norway led on this. There was a remarkable coalescence of political support around what became reproductive maternal, newborn child and adolescent health.

There were controversies, where's the place of safe abortion in this adolescence? What age do you go up to? But the broad movement that was created was extraordinarily powerful, and it was that social movement that led to this massive reduction in mortality. But then. And this is where I think we've made a big mistake.

When it came to the SDGs, of course the criticism was instead of focusing on children or mothers or women or whatever, we should invest in health systems and universal health coverage should be a goal. Of course, it should be a goal in one sense, but if you are a politician with limited budgets.

Investing in the whole of universal health coverage where you don't know where the money is going and there's no human being clearly at the end of it was a strategic era. And so I think the part of the reason why we've seen the pace of success, Hal in the SDG era is because we've not, we've taken our eye off the main the main goal, which is.

Women and children, and that's where we are today. And we need, as we are thinking about what comes post 2030, we really need to refocus on the individual, the human being. I always remember, and you in these, with these abstract issues, you have to put the human being at the end of it. I always remember Gru Harland Brentland in WHO.

And she put it so well. Poverty has a woman's face, and so instead of thinking about GDPs and growth and the economies and whatever, no. You think poverty has a woman's face and immediately you can picture. What you're really trying to achieve, and that's what we've lost. 

Jessamy: And bringing that back sort of full circle, I should also want to do, bring in this publication by the UN Maternal Mortality Estimation into agency groups.

So they're saying that in the year 2000, nearly half a million women died from giving birth. And that figure in 2023 is now just over a quarter of a million. So another enormous success. One of the main messages that I took from this commission on reproductive maternal and newborn child and adolescent healthcare was the fact that we are making progress, but it's much, much lower. And these three things that are making it slow, much lower, which are economic trends. So in 20 21, 50 8% so 25 countries of 43 countries in Sub-Saharan Africa spent more on public external debt servicing than on health. The second one is on armed conflict.

So in 2022, an estimated 327 million women and 507 million children live near conflict zones, which is 29% increase for women, and a 24% increase for children since 2015. These figures are enormous. And then the third thing is on food insecurity. That's been rising over the SDG period, and now, to come full circle back to Trump.

These global executive actions are gonna have such an impact on each of these three things that have already been stalling progress. 

Richard: Absolutely. Absolutely. And the number one recommendation in the R-M-N-C-H commission report is. Refocus on Africa. And of course that's the continent, Sub-Saharan Africa, which is gonna be hit most by the the Trump cuts.

Yeah, it's a and Africa should be, it's not just for children actually. It's or maternal mortality. Africa needs to be a much greater focus for us in global health generally, as you. As you see the population expand from 1 billion around 1 billion today to 3 billion by the end of the century, as our Nigeria commission from a few years ago argued very eloquently.

This is an amazing opportunity to, see the demographic dividend that comes from that population growth could fuel the kind of creative explosion in the continent that is unimaginable, but only if we understand what we have to do. And health is part of it, but it's actually probably not the most important bit of it.

The most important thing is in education. Unless you invest in education, you think of all the young people. What are we saving these children for? If we're saving these children to have no primary, secondary, tertiary education to have no prospect of a job, what's the point? We might as well forget, let's close all the child survival programs tomorrow.

And that's actually, I think, a very fair critique of the Child survival movement. That survival isn't the goal, it's stage one. And then what's stage two, three, and four? And we haven't had that strategy. And as we see WHO implode because of cuts and the UN generally on the defensive, I'm not sure in the next few years we're gonna see that strategy emerge.

But that's where the academic community can play a part. And I think that's I don't want to oversell it, but I do think that there is an unrealized potential of the academic community with its access to data, its ability to synthesize knowledge and the platform of not just the Lancet, but the thousands of scientific journals out there.

If we work together in partnership, then we can create that front of knowledge that can, that can hold political leaders accountable for their promises or, and commitments or their lack of promises and lack of commitments. 

Gavin: I, I think if we had more time, I would I would put it to you. Where are we on 2030?

And also you mentioned it there we're in trouble, Gavin. Yes. 

Richard: We're not gonna, we're not gonna get there for child survival targets or maternal mortality targets. 

Gavin: But I was gonna say this would make an excellent topic for the next podcast. So perhaps next time around we can talk about where are we on 2030, but also, 'cause you teased at it there, what comes after 2030 I think is a really interesting discussion.

I guess tune in next time for that one. But for now, Richard Horton, Jesse Baggin, thanks very much for joining me on the podcast.

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