Health in India and global funding cuts

Gavin is joined once again by Richard and Jessamy for a chat about the latest in global health news and the world of Lancet publications, this month covering The Lancet's new Commission, A Citizen-Centred Health System for India, and a new paper in The Lancet Global Health on the effect of global development assistance funding cuts.

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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 and welcome to The Lancet Voice. It's February, 2026, and I'm Gavin Cleaver. I'm joined once again by Richard Horton, Editor-in-Chief of the Lancet and Jesse Bagenal, publishing Director at Elsevier to discuss the world of Lancet publications and global health news. This month we're looking in detail at health in India, off the back of our New India Commission, and we're talking about global health funding cuts.

We hope you enjoy the conversation.

Richard Jess, me. Welcome back to the studio. It's been, uh, it's been a while, I think October last year since we all last sat down and chatted with each other and a lot has happened. 

Richard: I missed you all and Jess me. Left, 

Gavin: left the Lancet. Yeah, that's the headline. 

Richard: She's now making a guest appearance. 

Gavin: Are you on Lone from?

From Elsevier 

Jessamy: temporarily. Just, yeah, and, and by the minute really it's 

Gavin: the cost is adding up. How has your new role been? 

Jessamy: Very good. Very good. It's very interesting to understand publishing from a new angle. 

Gavin: What is the full title that you now have? 

Jessamy: I am publishing director. Of HMS five. 

Gavin: It sounds a little bit like a boat of some side.

I feel 

Jessamy: like it's, yeah, it's very pragmatic. Uh, our top, we have 190 journals and they cover surgery, orthopedics, uh, max facts, vascular, endocrinology, pediatrics, diabetes, some internal medicine. A real mix. 

Gavin: How's your last six months been? Rich? I assume you're still in charge of the answer. 

Richard: They haven't got rid of me yet.

Yeah. Um, no, it is been super busy. We had a great end of year. We had this series on ultra processed foods, which got a lot of attention, uh, more attention than most of our series get because everybody in the world is just completely wired about ultra processed foods and how dangerous they are. So that was great.

But we've been watching the world unravel, haven't we really, Gavin? I mean, I think it is been, um, the last six months has been a pretty depressing time. Just looking at it at, from a helicopter view, we've seen more attacks on science, RFK and his quest to destroy the established evidence around vaccines has been deeply problematic.

The institutionalization of disinformation. Across many scientific agencies such as NIH and CDC in again in the United States is deeply worrying. We've seen the full extent of the cuts at the World Health Organization. Be delivered. It's good that those are over and the WHO can start afresh in 2026. But, you know, we've really seen some pretty savage reductions in personnel and therefore narrowing in the scope of what WHO can do.

So I think it is, you know, we've gotta retain our optimism and, uh, try and build on what we've got. Um, and so the, I would say the role of scientific journals. In our little corner of the world, what The Lancet does is even more important than it's ever been, but it's been a pretty tough time, I would say the last six months.

Gavin: I was gonna say, even as a kind of news junkie, I've completely lost track of it by this point. It feels like every week something different and terrible and something that in a previous time would've been almost kind of era defining that happens anew every, every week or so. It feels like, 

Richard: yeah, the rules based order that we've based so much of our.

Lives around in, in health, uh, and development just seems to have been ripped up. Um, and you know, we, we've got an editorial in this week's issue on, um, the situation in Venezuela. Written by one of my colleagues who is, uh, Spanish and so is therefore able to make contact with individuals in Venezuela who know exactly what the situation's like on the, on the ground and the situation in Venezuela for, you know, 20 million outta 28 million people are living in poverty in that country.

And Maduro, nobody wants to defend what he did, but. The way that the United States came in and decapitated a regime in a country, even a regime as bad as Maduro's regime was, and then essentially appropriate the oil reserves and have this extractive approach to, to the resources that Venezuela does have.

Uh, this is not the way the world should be run. And in the editorial Bayer, my colleague, has described the situation for health in Venezuela, 20 years of it being driven into the ground on the background of several hundred years of colonial. Colonial colonialism. Um, but the situation today is really, really appalling.

And the United States, as well as the new Venezuelan government ought to be paying a lot more attention to the health and wellbeing of its people. At least that's what we try and say in the editorial. So I think there, you know, we're, we're only a bunch of journals, but I think what we can do across our portfolio 20 or so journals in your portfolio of hundreds, Emmy, is that, you know, every act of resistance matters.

Um, every, every attempt to defend science, defend scientists does make a difference. And I think that's, that's our role and it has become ever more important in today's world. 

Gavin: What was the state of the Venezuelan health system like even, you know, under Majuro? 

Richard: Unfortunately, um, it's very difficult to be sure because they destroyed all the epidemiological surveillance.

So there's very little data that one can actually rely on to tell you what the situation's like. But what we do know is that there have been rises in malaria incidents. So infectious diseases have surged back in many parts of Venezuela. Access to essential medicines is extremely poor. Um, so people are not going to get the quality of care that they should be able to get for a country like, uh, Venezuela.

And then Advanced Specialist Services, they just don't sim, they simply don't have the specialists there. Something like seven or 8 million people have exited Venezuela during the Ugo Chavez and Maduro era. You know, there's no question that, that they, their governments stood for something that was very positive and meaningful in the sense of trying to defend the rights of the poorest and most marginalized people in Venezuela, in many rural communities.

But in doing that, they have destroyed a health system that now is not able to deliver basic care. And by basic care, I mean. Primary healthcare and the most fundamental essential services. So not only are 20 million outta 28 million people living in poverty. But a very large number of the population are just not able to get those AC that that access to basic care.

So this is where it's a humanitarian emergency and America might come in and talk. We're talking all about the narco state and oil and gas and Maduro, but actually somebody needs to be talking about the people and nobody's been talking about the people. 

Gavin: Well, I feel like I can ask you about any health system in the world, and you'll have a pretty good answer about how the health system runs, which, uh, which brings us on nicely, I think, to India.

Um, and we recently published a commission. So, uh, why don't you tell us, well, let's start about how did the commission come about? Why is this a good time for, for this commission about health in India? 

Richard: Yes. So we published in 2011, um, a series of papers about the Indian health system calling for universal health coverage in India.

Um, it was a, it was a fantastic series. It was led by a guy, good friend of the Lance Rin Ready, who led the Public Health Foundation of India. We're very fortunate. He was Manmohan Sing's personal cardiologist. And so when we went to launch the series in Delhi, we actually got access to. Prime Minister man, Mohan sing himself and presented it to him in person.

But I think the truth was that we were going to the top of the hierarchy in, uh, India. It was a very, very technical series. And it didn't actually make too much of a difference. I think some of the ideas got incorporated into the 2017 National Health Strategy, but we, it was a very top down approach and a bit of a technocratic approach to, to trying to reinvent.

India's health system. So this time this project was led by somebody again, who we know very well. Vikram Patel, who's based in Goa, um, is also a professor in Harvard. And Vikram wanted to do a kind of bottom up approach. So this is, this was a commission that's called a citizen led commission on the Indian Health System.

And it really starts from the people and analyzes what the problems are for the people and then tries to build up. From that it was, it's been a five year initiative started at the beginning of the pandemic, and uh, it's been a complicated project to do because. India is a complicated country. You know, it's 28 states.

It's not just one country. It's like 28 countries in its own right and a whole bunch of separate territories. And a lot of the health budget is devolved to states. So it's not like China where if you've got Xi Jinping and he makes a decision, then that's what the whole country does. It doesn't work like that in India.

This is the problem of democracy, is that everybody has a voice and that slows things down. So it makes this kind of project more challenging. But that said, we, you know, the, the, the authors navigated trying to bring together the public and the private sector, which was one of the most difficult predicaments they had.

You know, the system should be based on the public sector, free access to healthcare at the point of demand. But there is a very vigorous private sector, which is where the elite and many of the middle class use. And of course, if you've got a vigorous private sector, then doesn't the attention, the political attention is not put on the public sector because there's no demand.

So we need to strengthen the public sector, align the private sector to the public sector. And this is what the commission has tried to argue. So we launched it in Delhi a couple of weeks ago. We had a fantastic symposium for a day. Um, we didn't present it personally to Prime Minister Modi. Um, but that's okay because what we want to do is not have a top down approach.

We want to take the commission to individual states and try and put the recommendations of the commission. Into practice in those states and take a few exemplar states, and that's what we're gonna do in the coming months. 

Gavin: Any highlights from your whirlwind visit to India? 

Richard: Uh, yes. Several highlights actually.

First of all, the Jaipur Literary Festival. Jaipur is about a three hour drive southwest of Delhi, and it's organized by this Brit William Pul. Uh, but it is the most fantastic literary festival that I've ever been to. Mostly Indian and, uh, south Asian speakers. There were sprinkling of, uh, internationals.

We had a session at the festival on the commission, um, led by Vikram Patel. But it's just, it was just a fantastic way to see a different perspective on the world. You know, you get so rooted. Here we are in London. You see the world through London's eyes or the anglophone eyes. And you go and you, you see the world in a completely different way.

For example, you know, India, we are all talking English, but the fact is India is a country with hundreds of separate languages and there are many sessions talking about the, the hegemony of the English language and how that destroys literary traditions and cultures. And of course we don't tend to think like that.

We take for granted our English language. But you go to India and you realize that actually colonialism is still very much alive and operating on a day-to-day basis. So it was, no, it was, uh, it was a, it was a revelatory visit. And I think the second revelation I had was, I had the same feeling in India in 2026 as I had when I first went to China around 2006.

That is to say this is a country with enormous energy and a lot of money. And is on the move. India's economy is, it's one of the fastest growing economies in the world of any comparable nation. And if you look at the growth of their scientific output, number one in the world is China. Number two is the United States, but number three is India.

And it's not a another European country, it's India. And India is growing at 14% output every single year the same as China. America's growth flat zero. European countries flat zero, even negative in some. So, you know, this is a country that's moving fast. Sure there's a quality issue, but there was in China 20 years ago.

Um, they'll fix that and they are fixing that. And remember this about India, 60% of vaccines in the world. Where do they come from? India, 40% of generics in the world. Where do they come from? India, you know, it is the pharmacy of the world and it's a digital technology superpower already. So, you know, I think, you know, we all get obsessed about China.

We all get obsessed about the United States of America, and everybody forgets about what's going on in India. And it's a super exciting country. 

Jessamy: Let's just dig into that a bit more because obviously China, India, similar populations, India's the most populous, but China, you know, very closely behind massive, massive population, massive amount of young people in India, less so in China because of historical, you know, family planning.

But when we look at investment in science and research and healthcare, and you think back to your time in 2006, are these countries on similar trajectories? When we are looking at that, that type of investment in infrastructure and in in health and science research, 

Richard: not yet is the honest answer. Um, but maybe I'm, maybe I'm unfair by saying that, I mean, if I try and think back to 2006, the government wasn't, you know, I, I didn't think about Peking University Medical College, or Shinga University or any of, or Udan or any of the great universities in China in the way that I do now.

Um, they had not matured and flourished, um, and the government wasn't. Taking them as seriously as certainly they, they do now. And it's true that in India also it, it is hard to name universities, thus are of that international caliber. And also I think the, the balance of where the research is done is different.

So it is right that in China there's a lot of investment in medical and life sciences. In India, it's more on the physical sciences, computational science, and less so on the health sciences. So there is a sort of different agenda, but again, I think this is where the opportunity comes for India. They've, this massive economic growth is creating this fiscal space.

And that fiscal space can be invested in health, in research, in education. Um, and certainly the middle class, which is now, you know, hundreds of millions of people, which it wasn't some years ago, is clamoring for that. You know, their aspiration is to have. Health, education, universities exactly like China.

So I, I feel very, although it's different and although it's more complicated, um, and more fractured, I still feel came away feeling very, very optimistic about, um, about the future and that we need to be there. Mm. 

Jessamy: And what about this aspect of. You know, one of the, one of the findings is that kind of these, you know, averages of data, of improvements on things is hiding these very deep disparities because of this very pluralistic way that they're running their healthcare system.

So you have massive disparities in delivery and inequality. What did you see when you were there that. Felt like people either really calling to change that or to address it. And, and what are the levers that could be pulled? 

Richard: Well, I think the answer to that is not enough. Um, so. I do find it astonishing that a country can allow 640,000 under five children to die every year, and there aren't protests on the streets.

That seems pretty shocking to me, but this is a country that allows that to happen. And under five child survival is not a mainstream priority that you see debated in the newspapers every day. That said, certain things are priorities. So I was in Delhi for a week every single day on the front page of the newspaper, there was a story about air pollution and how this was not being tackled by the municipal authorities or the government, and the things that they were trying to do were utterly failing.

So. You know, people sometimes say that the Modi government has created a culture of self-censorship and the media isn't as free. I hear those stories, but I tell you on the front page of the Hindustan Times, every day the government was being held accountable for not addressing the severity of air pollution.

So there is a vigorous and vibrant media, it does hold the government accountable. I just think it's the issues. You know, health is not. An issue of political salience like it is, for example, in the uk. The NHS is number one or number two, issue with the economy in any political debate. Well, it sure isn't in, um, India, and that is a problem and I hope that what, what The commissioner can only make a small contribution, but what I hope it can do is to encourage more health activism, more demand for government action.

It is surprising to me that there is this passivity. Around the issue of health and that people aren't demanding, um, better services. 

Jessamy: Are there any political science? There must be lots of people that have written on that. They have countries in different stages of their development in terms of what people's GDP is in and the priorities in their life, and therefore how likely they are to demand better healthcare.

Whether that's it's, it is viewed as a luxury rather than as a necessity. 

Gavin: Not the spring to mind, but the question of demand is very interesting, isn't it? And there's salience with which these things come to the front pages, like you said. What, what's your perception of the kind of stage that India is at then when it comes to like, demanding, say, you know, getting all the way to universal healthcare being the number one or two most important thing in the country versus where India currently is?

Richard: Yeah, I, I did ask this question of, of many people I, I met, so, you know, in China, there's no doubt that the, the demand, you know, for, for a young family in China. They want to have better schools and better healthcare and better housing and better jobs for them and their family compared with their parents.

So China took, took 800 million people outta poverty. This massive middle class suddenly created with this driving ambition and aspiration to do better for their families compared with their parents. And that's driven the system. You know, this is, this is where for the Chinese Communist Party to stay in power, um, and for Xi Jinping to maintain his leadership, he knows he has to satisfy the demands of the people.

Gavin: So you think it's an equity economy issue? 

Richard: It's, I mean, certainly it, well, I, I think it's a political issue in the sense that. There's this massive middle class with these massive demands, and the government has to satisfy those demands, and they know that the way to satisfy those demands is by investing in these services.

I mean, the way it was put to me many years ago was Mao created the borders of modern China. Deng Xiaoping created the economic miracle, and the job of political leaders today is to keep this show on the road. And the way you keep the show on the road is you keep people happy, and that means meeting their aspirations around health, education, jobs, homes, and so on.

In India, it's D. It's a bit different. In India, they have this goal of biscuit barat, which is getting to a developed economy by 2047, so the Centenary of Independence. So they really have a national mission. And they're really, you know, clear goal that by this date we're gonna make it and everything is directed towards that.

But they haven't pulled 800 million people outta poverty yet. They don't have that middle class that is literally banging at the doors of government saying, you've got to give me schools education, health, and so. But it's growing. It is growing. I think also in, in India, and I, somebody said this to me when I asked him about the 640,000 under fives and why aren't there protests in the streets?

And he said, look, Richard, you've gotta understand. Um, you know, we've come from being basically, you know, you guys in Britain destroyed our country. You extracted all of the wealth from our country. We were the richest, one of the richest countries in the world before you guys came, you destroyed all of that.

We were a country, an independence that was basically in, in poverty. And how do you psychologically deal with that? The way you psychologically deal with that is that you just have to say, this is fate, this is how life is. You know, you just have to accept it. So there is a, this is the way somebody's put it to me.

There is in our, in our psyche, a sense that this is what one has to accept. Now you are building this middle class that does have this aspiration and this demand and that that's gonna change. It's not changing as fast as it's, as it's changing in China, but it is changing, and I think that's the hope for the future.

Jessamy: It is interesting though, you know, we hear all the time about New World Order multipolar, blah, blah, blah, but the same thing is happening in health and you know, we are comparing and contrasting India and China being reading that book, breakneck by Dan Wang. I'm just on the one child policy chapter, I mean, which is, you know.

Out of this world really the figures of abortions that were carried out. But that is very recent history that a government was having a direct impact on women's ability, on sterilizing them, on aborting their fetuses, and yet, almost within 10 years. We are saying, and I know that it's different because it was very much more rural than the urban classes.

And presumably when you're saying middle classes demanding healthcare, we're talking really about urban middle classes. Yeah, absolutely. Rather than rural. No, 

Richard: absolutely. 

Jessamy: But you know, this transition between accepting that a government is gonna be able to dictate how many children you have and to physically take you into a hospital and have bought your, your second child to demanding a certain level of healthcare within 10 years.

Is mind blowing. So I I, I, I think what you're saying is absolutely right. We might be sitting here in 10 years time, and it's a very different situation in India in terms of that demand and what is required by citizens. 

Richard: Absolutely. I left. Feeling the energy in this country and wanting to go back and, um, and, and experience it.

Absolutely. It felt really, really a moment of, um, optimism. But I want to, I want to change tack for a moment because we talked about Jess's new job. 

Jessamy: Yes. 

Richard: But there's another new job here in the room, and that's Gavin. You've got a new job. Tell us about your new job. 

Gavin: Yeah, bring the cake out, get the streamers.

Richard: Come on. 

Gavin: Uh, I'm senior editor now at the Lance Global Health. First, you've crossed 

Richard: the line. 

Gavin: I have, I've crossed the line from comms into, into the light side, the bright side editor, the brightest, bright, bright side of editorial of editorial. And, um, yeah, I started doing that in October on Lance Global Health, Lance Global Health, working with a wonderful little team over there.

Um, led by Zoe, our editor in chief, who's been editor-in-chief of the Alliance Global Health since 

Richard: she's the founding 

Gavin: editor since it was founded. That's 

Richard: right. So, absolutely. 

Gavin: It's been an easy place to come into. Yeah. Because, you know, it's very, um, it's a very well established journal and all of the, all of the research that I'm helping authors work with now is so interesting and fascinating.

'cause, you know, it deals with these. Vulnerable populations. So it, it's, so much of what we publish is this incredibly worthwhile stuff that hopefully will make a difference to vulnerable populations around the world. 

Richard: But listeners may not know. I don't wanna sort of just read out your cv, but you have a PhD in political science, so you are bringing a very, very unique perspective to the work of global health, which is, which is really important, not just the politics, but the fact of a, a, a more social science.

And maybe qualitative research perspective to the work that is done at the journal and actually not just at the journal, but you will have an impact on the whole organization because you join our manuscript meetings and, and, and other meetings. So 

Gavin: yeah, I've really actually been surprised by how easily, I guess that kind of background, my background in politics and policy.

Has slotted into what the Lance Global Health does. 'cause you know, it publishes obviously randomized controlled trials of drugs in particular populations, but it also publishes quite qualitative work that overlooks how policy interlocks in different countries or different regions of the world. And I'm handling a really interesting paper at the moment, for example, uh, that's a qualitative overview of the entire, they call it the vein to vein system of blood transfusion, uh, the blood transfusion continuum in Kenya.

Yeah, and it's interviews with hundreds of people, uh, who are involved in that situation. Uh, it's, you know, full of, full of quotes, full of how can we make actually the entire continuum better? And it just makes you think of the sort of work that can be done in these areas that's not always quantitative.

You know, we have to kind of figure out where the, where the problems are before we can address them with quantitative work in quite a lot of areas. And, um, I did a podcast for Atlantic Global Health recently as well as part of our. A fantastic issue on implementation science that was looking at working with indigenous populations in Guatemala.

And um, I spoke to the lead author on that paper and what was really fascinating about talking to her was she was, she was talking about the extent to which the quantitative work that they eventually did, which was mental health interventions of an indigenous population in Guatemala. It would've been impossible without the qualitative base that they had to build the work on.

'cause they had to go into those communities. They had to talk to leaders, they had to talk to families. They had to work out where their knowledge base of clinical work with mental health interventions overlapped with the knowledge base of mental health interventions among the local populations. They all had to sit down in a room and work out where the overlap was, what was possible, and then how you can build the kind of clinical or westernized knowledge, uh, of mental health interventions into these particular settings, which are so different compared to, uh, how you would deal with, with mental health interventions in a, in a more clinical hospital based setting.

And it was just really fascinating because it just really made me think that work like that is not only so important. But this qualitative base that goes hugely underappreciated, I think is the foundation of work like that. So, um, I, I think we need to make more, more space for qualitative work. 

Richard: Couldn't agree with you more.

And one of the criticisms of the Lancet. As an idea is that we have follow a very biomedical model and that we don't do exactly what you are describing. Take a more descriptive, phenomenological approach to the world in which we live, and instead impose all of these experiments or quasi experiments on it, rather than just observing 

Gavin: meeting people where they are 

Richard: Exactly.

Beautifully put. So I mean, that's what you are bringing to the group and Fantastic. And I think you've got, I'm looking at what you've got in front of you. Is that one of your first papers that you Actually, this is the 

Gavin: first paper that I've taken from start to finish to publication. Um, but it actually does build on a paper that the weekly published last year, which was the, uh, paper modeling, the U-S-A-I-D cuts and the impact that they would have in, um, in low and middle income countries that, uh.

We're not reliant on, you know, on U-S-A-I-D funding, but, uh, it was formed quite a large part of the health systems and health interventions in that country for some really high impact conditions. And so what this paper does is kind of build on that base. But what I think is really important, uh, is because obviously the U-S-A-I-D cuts kind of dominate the headlines, uh, when it comes to overseas development assistance.

It actually expands the analysis out to include all of the cuts in, um, Germany, France, and the UK and other countries. The funding from those countries contributes roughly 70% of all of overseas development assistance. But there's some really striking figures when you get past thinking about just the US contribution to to U-S-A-I-D.

So the U-S-A-I-D cuts have been roughly 56% of USA overseas development assistance to all of these countries that are being looked at. But then the UK's cuts, which get virtually no headlines whatsoever, have been 38.9% of the UK's total overseas development assistance funding. So when you think, on the one hand, we've got these huge headlines about Elon Musk going in and as he says, feeding U-S-A-I-D into a wood chipper.

Actually the UK's not that far behind in terms of its cuts for, for overseas assistance. 'cause it's 

Richard: all gone into so-called defense. 

Gavin: Exactly. Yeah. Yeah. And then, um, 36% for Germany. So very similar to the uk. And 18.5% for France as well. And in the words of the, uh, authors, similarly large decreases for nearly all other donor countries with only a few exceptions.

So it's a real broadening outta that article in The Lancet from, from last year 

Richard: who did this work? 

Gavin: Yes, it's David Eller. And so the way that the work was done for, for listeners who are, who are catching up, um, was that they looked at the period 2002 to 2021. To see the extent to which overseas funding, uh, saved lives during that period.

You know, we obviously, we had huge gains made in under five child mortality, for example, and then removing certain percentages of that funding and looking at how that might have an effect on, on lives from, um, 2025 up to 2030. And they ran three funding scenarios looking at, uh. A severe defunding model, which, uh, projected the current cuts and then followed by further substantial cuts, which is quite likely, I would say up to 2030.

They had a mild defunding scenario, uh, which was the, the same cuts as are currently, uh, in place, but with a kind of stabilization just after that. Uh, and then a kind of business as usual at 20, 23 levels, which is when all of these cuts started happening really across the board. And in the severe scenario, they.

Found that the likely excess mortality would be 22.6 million people up to 2030 from these cuts, 5.4 million of them being children under five. So it falls to a huge extent. You know, so much of this funding goes towards maternal and child health in these countries. And honestly, those are, as we've talked about before on this podcast in the past.

Those are the, the major incredible headline gains that we've made over the last 20, 25 years. So it's a real dialing back of, 

Richard: can I be a devil's advocate please? So we've received papers similar to that, making projections and drawing scenarios for the future, all terribly apocalyptic. The bit that is missed out from the analysis is, okay, so you've cut ODA.

What you haven't factored in is that the recipients of ODA May now as a result. Assume their responsibility and exercise their sovereignty. And start to fill the gap that ODA was filling before, 

Gavin: which is the really important point to make, isn't it? Because there's, there's an excellent letter, which I've actually got in front of me as well on the weekly, in a response to your original study from Daniel Krugman and say, ya, Ebola, talking about how this is such a kind of colonial way of thinking, you know, the.

The only way that these lives could have been saved was this kind of heroism narrative of, of the west intervening. Right. With this money. Right. Whereas actually, if you look at it from a positive, not just not, if you look at it from the sense of these places having agency, which obviously they do 

Richard: mm-hmm.

Gavin: It's a chance for them to build these structures up themselves in a way that's so much more sustainable than relying on the whims of Western political back and forth. 

Richard: And even worse than that is, is the whims, but also we, we create parallel. Funding streams, parallel monitoring and evaluation streams, parallel accountability streams.

Um, I mean, it, I, I remember I was at a meeting, um, it was to do with the Global Fund and of course the Global Fund does fantastic work. I wouldn't take anything away from what it does. I wanna be the strongest possible advocate. But the result of what the Global Fund often does is it gives a slug of money to a country.

And then the government will not unreasonably say, well, we've just got this slug of money from the Global Fund. Now we're gonna take all the Ministry of Health budget, take it outta the Ministry of Health. 'cause now the Ministry of Health doesn't need its budget and we're gonna spend it on education or something else.

So what happens often is that the this ODA displaces national health budgets, which of course is crazy. Um, and. That's not what you want. You, you, you want to actually strengthen the sovereignty of Nations so that they have complete control over their destiny. And ODA, in a sense pulls the rug from underneath the country.

Gavin: Absolutely. It's a, it's a very valid piece of modeling. Yeah. And it's important to show the extent. In some ways, I feel like it's almost a positive display of how ODA has helped over the last 20, 25 years. And I know you were just talking about how it has displaced Ministry of health budgets in some cases, but it is, I think, in a broader sense, making the case for, uh, these cuts not going ahead.

Richard: Sure. Uh, you, you, it shouldn't be either or should it? No, it's okay. It, but it is the way we do it. And the, and the way the, the ODA, the governance around the ODA and the way the, the money is distributed and who has authority over that money, that's part of the problem. It is. It shouldn't be the donor who's saying to the country, this is what you're gonna spend your money on.

And very often it is. What should happen instead is that the money that comes from the donor. Should go into the, the, the bank account of the country and then the, the country decides what to do with that money, not the donor. But too often that's not the way it works. 

Gavin: We have actually commissioned a link comment to go alongside this, which hopefully by the time this podcast comes out, we'll be live.

This, this paper was fast tracked, so. The comment's not quite ready yet. Right. But, um, Sylvia Kao, uh, has written an excellent comment about the agency of low and middle income countries in these situations and how. This is an opportunity for them to reorganize in a more sustainable, more sovereign way that, uh, doesn't rely on on overseas aid.

Richard: Yeah. And John Kase from Africa, CDC, he's an absolutely brilliant advocate for this, in a sense, renaissance of sovereignty in Africa. Um, and the, and the fact that this is, this is the big moment for African countries to assume a leadership role. Domestically and internationally, which they've never had before.

So I think he would see this as, as, as a, as a moment for them to seize. Accepting. Unfortunately though that the, that the savage precipitate nature of these cuts has, as you described, definitely led to and will continue to lead to unnecessary deaths. 

Gavin: Yes. It's kind of that, um. The sudden nature of them is such a problem, isn't it?

Because ideally, you would want a kind of tapered pullout that allows recipient countries to rebuild these systems in a way that's more sustainable and works for them. But that simply hasn't happened. Lots of these programs, as we've heard in the news, have just stopped overnight and just caused complete chaos.

Richard: Yes. I mean, I, I, I remember somebody saying to me, this was in South Africa. They were receiving funds for a program of work. Sex workers giving advice about around HIV and they were being paid not to do sex work, but indeed to work in this NGO to give advice. The funding was suddenly cut, and now these sex workers are now going back doing sex work, putting themselves at risk of violence as well as.

Acquiring HIV. So I mean there's, these have had materially appalling impacts on people's lives, 

Gavin: but we seem to be at a moment where the whole world is reorganizing itself. You know what I mean? That we talked about at the very beginning. These structures are, that used to kind of not govern the world, but help us understand the position where everyone sat in the world and how how structures and countries interacted with each other have fallen apart.

And if you look at it in a positive sense, it is. Interesting and important moment because now we have to start building a different future. 

Richard: Yeah. Um, I, I 

Gavin: prefer to look at things in a positive way like that, Richard. 

Richard: Yes. No, I, I, and, and I do too. Um, but the rise of I can sense 

Gavin: a but coming 

Richard: there of populist politics and, uh, it feels quite hard to retain that optimism at the moment when we're going to have.

Prime Minister Farage, um, in the United Kingdom, president Lapin in France. Um, she's legally 

Gavin: barred from a standing, 

Richard: so, um, pre well, alright, um, Jordan Barbarella, um, he will become the next president. Uh, you know, you are, you are seeing this research, well, this rise of a populist right wing politics that is going to promote the national interest over the way we look at the world, which is the importance of cooperation and globalism and that how does one win that argument back again, we have to admit those of those wooly minded liberals of which the Lancet is full, that we, we lost that argument.

We didn't bring people with us, 

Jessamy: we lost it. But we also, I think were complacent. We were lazy, and I think we wanted to have it all. You know, we failed to realize that most people, if they wanted to have great jobs, be super international, have all of these values that they could hang on a coat peg and say how fantastic they were.

At the same time as having relatively low taxes and not investing in schools, and not investing in healthcare, you can't have all of those things together and leave behind a whole group of people whose lives haven't improved over the last 20 or 30 years. So I think I was in a, a meeting last week with some really lovely people from the Army who were medics.

Talking in a way that is ex, you know, it's self-righteous, but there's also so moral and so many good things that they had to say. You know, the link between kind of military spending and advancements in medicine, which is very real in trauma care, but talking about the world in this very structured, archaic way of politeness and values and what was good and what was moral, but at the same time as.

Always wanting to make sure that they didn't pay too many taxes. Always wanting to make sure that their kids could go to private school. Always wanting to make sure that their lives. Were not impacted while they carried on sort of supporting a structure, which was really disadvantaging a whole group of people.

And I feel we've not grappled with that yet. And we, and, and what can we expect? But populism, when we haven't delivered, we haven't delivered to people better healthcare materially. In the uk we haven't delivered better education to them. I dunno what else we can expect really from a lot of people. 

Richard: Maybe what we have to expect is that we will see the populism put into power a, a whole set of politicians that certainly here we don't particularly admire and watch them fail.

Jessamy: Absolutely. 

Richard: And, and it will be outta their failure. That, that something else. That would be a renaissance of understanding that there are no simple solutions. Yeah. And that actually it is better for countries to work together and that it actually is better for countries to form mu form unions. Yeah. Um, and that the idea that there's some beautiful nirvana of, of, of being an independent sovereign state in this world is a myth.

Jessamy: But also that for the middle classes and for the aspiring classes, that you can't have it all. You can't vote for successive cuts in public funding and carry on in a rules-based order that you aspire to. There has to be more sacrifices. 

Gavin: On 

Jessamy: all part, 

Gavin: there has to be an ability in the political class to have a serious conversation with people rather than say that you can have these cuts and also have these services when the two things just simply don't go together.

Richard: And I'm afraid, although I, I do of course love the idea of living in a democracy. It doesn't mean to say it doesn't. What's coming next? Well, there is a, but there is a but because I find myself getting increasingly infuriated actually in a rage about the way the media exploit political issues for their own narcissism.

Hundred percent. And, you know, the rise of the journalist as a political personality commentator. Um, and, and it's, you know, just look at the number of podcasts that have proliferated. We're on a podcast here, a certain sense of observ observation. That's irony, isn't it? Observational irony about, about this comment, but you know, every political journalist of any channel in the world has their own podcast and.

They, they get attention by being critical, and the more attention they get is correlated with how critical they are and how extreme they are. And so some of our most cherished institutions like the BBC. Like Voice of America and NPR, um, get destroyed and they are the glue, the fabric of society that conduct a conversation amongst the people they end up getting destroyed or attacked by.

Populous media, um, or politicians or, or journalists who it's more about them than it is the issue. And, and it, it makes me mad to turn the radio on the mor radio on in the morning and hear these journalists criticizing a government in, in our case, in the UK there's only been in power for 18 months. You know, at the beginning of a five year term with a 14 year inheritance of austerity and having destroyed so much, and they're trying to reconstitute literally life in this country, and they're not being given the chance.

And I, I feel, and, and I think you're seeing the same, uh, the way the media has treated the Biden legacy. I agree. Um, which, uh, um, is portrayed as some sort of communist takeover, which is, which is obviously ridiculous. So it feels like. The media doesn't give governments a chance, so I don't think we have a healthy media landscape 

Gavin: either.

I just thinking how my ideal job would be a New York Times opinion columnist. They, they get paid like a mid six figures to write a factually incorrect opinion once every two to three days. I think it's, it's a dream, 

Jessamy: but it's also difficult, isn't it? Because you go, I mean, I, I feel like even the, even the statements that I've made during this.

Podcast you, I go into anything with a certain amount of anxiety that we are going through this extraordinary period of change and you can hear things that sound quite definitive and straightforward and you're like, oh yeah, that's right. That clarifies it. And then you reflect on it later and think, actually no, that it's such a complex time right now with so much change.

You almost wish that we could just sort of look at it for 20 years from now and be like, oh, that's. That was what was happening. That was what we were living through. Well, I think, and it's very difficult to see it. 

Richard: Yeah. Well, I think we are going through a transition. We are, I mean, neoliberalism began with Thatcher and Reagan actually, neoliberalism was the parent of globalization, and now we're seeing the end of globalization and therefore the end of neoliberalism.

We're in this transition now to this new era of. It's all about nationalism and all the global institutions are being defunded and destroyed and marginalized. So, and now it's every country for itself. And 

Jessamy: I mean, don't forget the Board of Peace though, because that 

Richard: Yeah, that is gonna keep 

Jessamy: everything 

Richard: together.

Jessamy: So 

Richard: the new United Nations and this era that we're now moving into of extreme nationalism and force will win out. That is a very, very scary world and, and especially for a brexiting country that has nothing that that has, is literally floating, floating in the middle of an ocean. It 

Gavin: wasn't great timing.

Richard: It wasn't great. That's the understatement of the podcast. Um, exactly. Uh, so we're really in trouble and, and, and this is an opportunity for Europe actually to assert itself. It was interesting. The day I was leaving India, the hotel I was staying in, as I checked out, Ursula Lvo Dela was checking in, um, because she was the chief guest.

Gavin: Was she next to you at the check-in desk? 

Richard: She, she wasn't next, but literally all the, all, all these military people were outside the hotel and I said, what's going on? What's, you know those, I mean, hundreds of people with very, very large guns. We're in the car park of the hotel. I said, what's going, oh, URS V Land's coming in because she was the chief guest for Republic Day.

Um, I was leaving on the Friday and she was coming in for Republic Day on the Monday. And the point is that Europe does have global leadership. They were just striking a new trade with India. They've just struck a trade deal with Latin America, the CIO deal. You know, Europe does have leverage here, and I think there's a set of European values.

Europe has a civilization. 

Jessamy: I think that's what we need to, we tap, need to tap into more is what, what is it that we stand for? And we've had difficulties with public services and health and everything else, but what is it about Europe, about Britain, where we are, or any of these other countries that we can say this is, this defines our future.

These are the the ways that we want to live and this is what we can deliver. 'cause we don't have what China has. We don't have what India has. We, you know, definitely don't have or want America has. So what is it? 

Gavin: Well, I think the attempt within the EU at the moment to create a kind of second track of the countries that are committed to tighter integration and that kind of European ideal is sort of an extent to realize that, right?

Because so much of EU policy is thwarted by outliers like Hungary who have a veto, you know, and obviously don't kind of cohere to the general values of the central EU countries like Germany, France, Spain, et cetera. That this creation of this second track, I think is actually an attempt to kind of grasp that nettle of, what is it, 6, 7, 8 countries that are all very, you know, very big financial powers, but also on the same level to the extent that they are kind of able to operate as this one block, which the European ideal hasn't quite worked in terms of.

Constant expansion with the coherence to operate as a block in the way that you're talking about, I think, 

Jessamy: I feel like The Lancet could do something in this space. Richard Commission or series of 

Richard: On the Future of the world. 

Jessamy: On the Future of the world. Yeah. 

Gavin: I'll leave that one to you. 

Richard: That's how we should end 

Gavin: well.

Okay. Well thanks everyone so much for listening. Thank you, Richard. Thank you, Jess for. Joining me again, we'll try not to leave at six months before the next one because I enjoy doing these. But, um, yeah, thanks everyone for listening. 

Richard: We'll solve we'll solve the problems of the world in the next podcast.

Jessamy: Exactly. 

Gavin: Yeah. Maybe we'll think about it in the interim and come back with some solutions.

Thanks so much for listening. We've put the links to the papers we discussed in the show notes if you want to check them out, and hopefully we'll see you back here on The Lancet Voice next time.