Sarah awoke in pain again, alone on the mat, still reeling from the night before. She had not dreamed, not for months, that she could remember. Just waking with the pain inside her, the knowledge of her abandonment in the crowded house, and the emptiness that had been her future.
When the school closed “because of Covid,” Sarah’s father said it would just be a week, and she could help with the harvest. The fruit must be picked, anyway. When the harvest was coming in, the markets closed and it rotted in the store at the back of the house.
The broker had forwarded the costs of her little brother’s medicines when he went to hospital three months earlier, and they were to pay him with the crop. Sarah’s father explained that college was no longer an option, and she did what she had to do. The man was old and she hated the smell and sight of him, but he had paid off the broker, and now Sarah owed him.
About 20 years ago, increased funding began flowing into international public health. This came mainly from a few private sources, people who had grown up in wealthy countries and made their fortunes from computer software. Their investment levered further funding from corporations and governments through ‘public-private partnerships’ and added public taxes to the private funder’s priorities.
New foundations and non-government organizations paid people in poor countries to work on areas of public health that interested wealthy people. The World Health Organization (WHO), formerly funded by countries as a technical agency, gained new ‘specified’ funding from these sources, co-opting the WHO’s vast network and influence to further the priorities of investors.
This new funding was a win-win for international public health (or “global health”). We got larger salaries and lots of travel, leading wealthier and more interesting lives. Improved resources for disease programs such as malaria and tuberculosis reduced avoidable sickness and death. Behind this, a few very rich people were deciding the health priorities of billions.
They were not enabled by those whose health was at stake, but by those whose careers were at stake. Supporting the centralization of public health has become standard, whilst simultaneously arguing for its decentralization. Job security can paper over a lot of ills.
Private sponsors, and the Pharma companies in whom they invest, give money for a reason. Corporations have a responsibility to their shareholders to maximize profits. Investors look to increase their own wealth. Where health outcomes seem more measurable, such as X number of vaccines saving Y number of children’s lives, media and public attention also helps build a positive image. Improved sanitation and community health worker support may be a better way to stop children dying, but the public doesn’t get excited by clinics and toilets.
Global health divided into two schools. One side continued to promote public health orthodoxy, prioritizing high-burden diseases, local control and the importance of local economies to health. The 2019 WHO recommendations for pandemic influenza, for instance, point out that border closures, confining healthy people and closing businesses should never be considered as they would provide minimal benefit but would further impoverish poor people and do net harm.
The other school, far better funded, has been building a narrative that undefined health emergencies were an existential threat. They claim that these were best addressed by centralizing control, confining populations and imposing externally mandated responses such as mass vaccination.
Covid-19 gave the opportunity for the new public health to prove itself. The response demonstrated that population control combined with mass injection could successfully concentrate wealth, whilst ensuring greater overall poverty and transmission of higher-burden diseases. Human rights could be put aside, the importance of education and functioning local economies could be ignored. It also proved that, when salaries and careers depend on it, most public health staff will comply, however contrary their orders may be to prior understanding or ethics. This has been demonstrated similarly in past generations. A whole new pandemic industry is now being built on this foundation.
Once Sarah heard that people in rich countries have meetings to help people like her. She was taught in school about the government’s efforts to stop female genital mutilation, or ‘FGM’ as the ritual her mother had endured was now called. Some people had given her class laptops because education was the key to making the family, the community, and the country stronger. This would allow them to have less babies, more money and better health. This had made sense to Sarah, and the world had looked brighter.
Sarah doesn’t see the other students much now. She heard the school had reopened, but most of her old classmates were pregnant or had babies, and like her they knew this promised world was not for them. She knows they are not stupid – they know the virus was mostly a problem for old people, and that the same rich people who once paid for the school computers made lots of money from the vaccines they insisted everyone have for the old people’s virus.
They always knew the white people who had come to the clinic were very rich in their own countries, although they tried to look poor in the village. But they had never realized that it was all a lie. Theirs had not been irrational dreams. Even the broker who lent the money to her father had morals and went to the mosque on Fridays.
While a conference in Geneva applauded its next speaker, another spasm of pain cut into Sarah, in another and simpler room. This spasm seemed deeper. She could not think about these things anymore. Soon he would come back and she did not know how she would prepare his meal. Sarah knew a lot, about a lot of people, but that didn’t help.
UNICEF estimates that Sarah is up to ten million girls.
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