From consensus to consequence, the future of global health?

And a rant about Bass' substack...

I’ll admit it upfront: I’m a bit ambivalent about the lack of nuance in global health discourse right now. There are tons of people [on Substack and elsewhere] writing about how global health is collapsing, why everything happening right now is wrong, and why those of us on the inside must either be blind, complicit, or both. Emily Bass ’s writing is serious, informed, but also reflects this kind of perspective! (As an aside, I’m totally baffled by how much detail Bass in particular seems to know about PEPFAR’s internal decision-making. Who is her mole?!).

Anyway, I wanted to write today because parts of Bass’ assessment of the MoUs and the implementation planning process deserve scrutiny (check out her recent post here). And in particular, I wanted to push back on the framing and the insistence that everything about this moment is bad, misguided, or fundamentally indifferent to lives.

From where I sit (and I say this with humility, not triumphalism) shit is getting done. Often in ways that make me wince. But done nonetheless. And that matters.

Let’s stipulate the pain upfront. The last ninety days (if not the last 365 days) have been bruising. Programs and processes have been overturned. Institutions that once felt immovable have shown just how contingent they really were. Long-standing, epidemiologically sound priorities have been sidelined. None of this should be minimized. Trauma is real, and it has landed unevenly (on individuals, on organizations, and on already-stretched health systems). But here is the inconvenient truth that the current Bass substack seems to avoid: more substantive movement toward country ownership has occurred in the past three months than in the previous twelve years combined.

Not rhetorically. But in signed agreements. In decisions that were deferred year after year while the process itself became the product. Of course, execution is everything, and the proof will come only with time. But it would be foolish to root for these MoUs to fail. Too much is riding on them, for countries and for recipients of care alike, for anyone serious about global health to hope they do not succeed.

Bass is right about one thing: the process has been uncomfortable. It is compressed. It is transactional. It does not flatter the ecosystem that is familiar with laborious donor-led planning cycles. But discomfort is not proof of harm, and unfamiliarity is not evidence of malice.

Yes, U.S. interests are explicitly outlined in the MOU in ways that may feel transactional. But perhaps they always were; maybe we simply laundered them through softer language before. And yes, some stakeholders feel sidelined. That is regrettable, and in some cases, avoidable. But after three years inside PEPFAR, I can say plainly that the belief that legitimacy flows only from maximal inclusion has often served as an alibi for delay and obsfucation.

Like most consequential change, this one has arrived with force rather than finesse. I don’t love that but I’m not convinced ‘finesse’ was delivering what we said we wanted anyway. Whether this moment is ultimately remembered as a turning point or a failure will not be decided solely by what happens inside MoUs and ministries. It will be shaped by events far beyond them—by who and how power is wielded in places like Caracas or Nuuk, and by what unfolds on the streets of Minneapolis, where the moral character of the state is revealed in far starker terms. However, from my vantage point, this may be the beginning of something new—still undefined. It could yet lead to a more coherent and accountable Pax Americana in global health. Disagree? LMK…

Up next - a series of letters….