Jenny Zheng

In April 2020, the Rights Writers were asked what perspectives have been left out of the major debates on their topic, and how would including them increase understanding or contribute to progress on this issue.

Over the course of the past few months, we have discussed the impacts of the billions of dollars of aid funneled into Tanzania by the United States, Denmark, and other international powers. We’ve analyzed how this aid affects the health decisions that directly regulate the lives and the rights of people in East Africa and around the world. And we’ve looked at the consequences of these decisions over the course of time. But one crucial player that we have so far left out of the conversation is one that has filled in an abundance of holes as they appear and whose reach deserves serious recognition: China.

Within the recent history of global health aid—worldwide, in East Africa, and Tanzania specifically—China has emerged as a powerful and growing influence on health and human rights. In fact, when Denmark suspended nearly $65 million in aid following Tanzania’s implementation of anti-LGBT policy, China simultaneously promised to spend $60 billion in investments, aid, and loans in Africa over the next three years. Tanzanian president John Magufuli has put it simply time and again: Tanzania prefers Chinese aid over Western aid, because it always comes free of conditions and is never packaged with underlying political pressures.

It is no surprise that China has emerged as a major investor in African nations and now challenges prominent Western influences within the continent. This relationship formed in 1963, when Mao first sent a team of doctors to Algeria. Since then, China has evolved from a poor agricultural nation to the second largest economy in the world—surely a model of success for African nations which have been unable to parallel such rapid growth.

But how deep has China reached into its pockets to help countries like Tanzania? For reference, China has invested $75 billion on aid and development projects in Africa in the last decade, while the US invested $90 billion during the same time period. However, while the West is most eager to fund health aid, Chinese aid serves a wider purpose, including infrastructure development, education, and agricultural productivity. Of the over 1,400 aid projects, only around 1 in 10 are health related.

While Chinese health aid efforts focus mainly on malaria, Chinese has also provided aid through provisions of free Traditional Chinese Medicine techniques. Although this transfer of informal knowledge appears altruistic in its intent to provide more accessible medications and health practices, the human rights implications behind this aid are contested. While this aid can be wildly beneficial as a way for low-income individuals to access basic treatments, it has simultaneously allowed Chinese medical doctors to practice with insufficient training, minimal clinical experience, and misused medication.

China believes that this relationship is incredibly productive. As Africa’s largest trade partner for over a decade, China believes these economic benefits will increase human rights, socioeconomic freedoms, and access to healthcare for everyone. At the same time, however, Tanzanian citizens are sometimes forced to move out of their homes for meager sums of money to make room for development, leaving them without homes, resources, and any way of protecting their health. American officials see these occurrences as symptoms of “new colonialism,” perpetuating all of the existing problems of misinformation and manipulation in health and human rights that we have discussed these past few months.

Currently, China is looking to develop a $10 billion port in Bagamoyo, 45 miles north of the capitol city of Dar es Salaam, which could potentially turn into “Africa’s Dubai”. Plans to develop the port, however, were temporarily halted by President Magufuli out of fear that investors would essentially be able to sell and exploit Tanzania. It is extremely difficult to speculate what this port would mean for the people of Tanzania. Could a port like this lift countless people out of poverty? Could it exacerbate socioeconomic inequalities? Could it import new diseases along with a wave of “new colonialism”?

The influence of China and its impact on human rights in East Africa may be a game of chance.

Ultimately, locals appear to be optimistic about China’s presence in Tanzanian life, which may matter more than sensationalized propaganda and cat fights between China and the United States. China’s aid has helped tremendously in building up an entire country. It has the power to decide where hospitals are, what diseases are treated, what medical resources people can access, and ultimately who lives and who dies.

We should still be cautious of China’s influence on health rights, particularly since China has said little about erosions of human rights when they occur. But it is fair to recognize that its aid has made tremendous strides in forwarding the development of East African nations.

While researching for this post, I reminisced on my time between Moshi and Arusha, two large cities in Tanzania, and how both were full of Chinese signs and restaurants. I could see China’s influence on infrastructure, but never understood how truly expansive its reach into East Africa was until now. Still, Tanzania has one of the strongest growth rates in Africa with its eyes set on becoming semi-industrialized by 2025. It is undoubtedly on the right track. But it is still important for us to be intentional with where our aid is going. Donate to organizations with transparent partnerships with local communities and clearly defined goals. Read about these issues from different sources that may not always agree. Encourage our political leaders to advocate for health rights with their money, but without imposing neo-colonial power over developing nations.

Now is perhaps the most critical time to act.

In February, 2020 the Rights Writers were asked to discuss how a topic has evolved throughout the past decade (2010-now) and look at the issues that have changed significantly during this time period and how these recent changes have affected current approaches to this topic from governmental and non-governmental actors.

“Any western medical institution more than a century old and which claims to stand for peace and justice has to confront a painful truth — that its success was built on the savage legacy of colonialism.” – Richard Horton, editor of The Lancet

Last month, we opened up the discussion about how restricted aid can deliver strong messages about human rights; at its best, saving lives and preserving quality of life and at its worse, serving as a powerful tool to perpetuate human rights violations. This delicate relationship largely results from the complicated and unfortunate history of the evolution of global health from its roots in colonialism.

In today’s world, the goals of global health aid aim to generate equity and improve quality of life, yet the field continues to be marked by the unequal power dynamics of racism, classism, and residual exploits of the global colonial past. ­While nearly all colonies have been emancipated, terms like “global health” and “international aid” are still tied to old colonial powers and their sociopolitical ideologies. The division between the global north and south demarcate unequal distributions of power: The North being rich, providing aid, and the South being poor, needing aid—a dangerous notion to perpetuate. In only the past few months, there has been a rise of the movement surrounding the decolonization of global health, of eliminating such neo-colonial power dynamics, and ushering in a more humane path to development.

In the following post, we will explore changes in aid itself over the last decade, as well as its subsequent ramifications on health and human rights. The landscape of global health aid has changed both figuratively and literally, even down to the minutiae of data collection. Satellite imagery has become increasingly widespread and inexpensive, enhancing the ability to consistently source data on poverty, disease, and the human environment. This information feeds into a system of aid distribution that is also changing in composition: instead of the transfer of goods and services, there is a growing inclination from aid donors to directly donate money and let recipients decide how best to spend it. “Cash transfers” as they are referred, is projected to only grow in popularity in the years to come.

But are these newly popularized cash transfers doing their job? Studies in Rwanda answer with a resounding no. Pilot tests of cash transfers spanning multiple years showed no improvements in poverty rates, nutrition, or hygiene. In fact, these grants were often used to pay down individual debts, rather than being diverted to better feed children or other goals. This implementation problem has persisted throughout the decade and may require the dismantling of structural limitations—rather than just changing the means of distribution.

Aside from the actual composition of aid itself, the distribution of aid has also been in flux over the past decade. The lack of stability in aid distribution has powerful effects on those who receive aid and those who cannot. A remarkable incident of this can be examined through contemporary shifts in aid policies in Tanzania.

Over the last few years, Tanzania has cracked down on same-sex relationships–punishable by 30 years in prison–and any institutions that appear to support them. In 2017, Tanzania suspended over 40 community clinics that provide HIV/AIDS care, accusing them of promoting homosexuality. Meanwhile, over 1.4 million people in Tanzania live with HIV/AIDS. International aid agencies responded in horror. Denmark announced it would withhold $65 million in response to Tanzania’s anti-LGBT policies. The World Bank followed by withholding $300 million. Actions that seemed like a firm middle finger to the Tanzanian government and unyielding warnings to change its ways. But this doesn’t just hurt the government, it hurts the people. It hurts the people who are already disadvantaged, those who are labeled illegal, those who must already fight desperately for health care. Tanzania won’t be able to win the war against HIV if its policies discriminate against minority groups, and any international aid won’t be able to either if it never reaches these exact groups who need it the most. These power dynamics are not new problems in the world of development aid; however, it seems that even with Tanzania’s political stability of increased economic growth over the past decade, the nation still finds itself in the hands of overseas powers. While the right to health has generally increased, acute policies like these may act as a step in the wrong direction.

Beyond the effects of changing international health aid policy on vulnerable patient populations around the world, dynamic changes over the decades have also, at times, risked the lives and rights of healthcare workers themselves around the world.

Since the Ebola outbreak in the Democratic Republic of Congo began almost two years ago, a spotlight has been shed on the abundance of violence faced by healthcare workers. Hundreds of providers are killed while providing critical medical care, despite the establishment of health care neutrality (noninterference with medical services during conflict) originating from the Geneva Conventions. When health aid becomes muddled with the political implications associated with donor and recipient agendas, this aid can be powerful artillery in not only saving lives, but also costing lives. Aid efforts can often be dangerous to deliver, jeopardizing the lives of the very people tasked with protecting others. These dangers, however, have only increased over the past decade with the rise of global powers and polarizing political agendas.

And when all of these threats against human life compound, the harm is truly greater than the sum of its parts. Perpetuating these problems will undoubtedly stifle development, infringe on political freedoms and choices, and bolster human rights violations that have compounded over a long and complicated history of global health aid.

In January, 2020 the Rights Writers were asked to discuss an issue in the context of US political discourse (including public opinion, if desired) – is any relevant legislation being debated? How are different branches of US government engaged with your topic? Consider particularly the 2020 presidential race.

“Of all the forms of inequality, injustice in health is the most shocking and inhumane.” – Dr. Martin Luther King Jr.

While political discourse in the United States is not unfamiliar with discussions surrounding global health aid and its implications on human rights, these necessary conversations are far from common. The root of this problem perhaps lies in the dichotomy between widespread public support for aid and its lackluster implementation in federal politics.

On the whole, “food and medical assistance to people in needy countries” is favored by at an overwhelming 81% of Americans. And when asked to weigh different types of foreign aid against one another, the general public most adamantly supports “child survival programs, which includes prenatal care, immunizations, and nutrition”. When reminded of the federal government’s other spending priorities beyond improving the health of developing countries, pollsters remained supportive, with only 33% wanting to decrease it, 46% wanting to keep it the same, and 19% wanting to increase it.

Public opinion on foreign aid programs continues to trend favorably, despite its dissonance from the Trump administration’s recent policies. The Trump administration has recently proposed a 23% cut in foreign aid in its 2020 budget, including significant reductions to overseas AIDS and malaria intervention programs.

Within American politics, there is a growing mentality over the usage of aid as a “goody bag” to incentivize foreign leaders to fall in line with American policies. These effects can be seen in El Salvador, Guatemala, Honduras, Palestine and more, in which American withdrawal of aid has directly destabilized human rights protections and endangered lives. The most dangerous manifestation of this can perhaps be seen in the Mexico City policy, more commonly referred to as the global gag rule, which blocks federal funding for non-governmental organizations that provide abortion counseling or referrals, advocate for abortion decriminalization, or expand abortion services.

The global gag rule was first implemented in 1984 by the Reagan Administration, and was not only reinstated by President Trump in 2018, but also expanded to encompass all global health organizations that receive U.S. funding, rather than previously only applying to family planning organizations. A study of sub-Saharan Africa suggests the increase of unintended pregnancies and approximately double the rate of abortions since the policy went into effect. USAID estimates the accumulation of 6.5 million unintended pregnancies, 2.1 million unsafe abortions, and 21,700 maternal deaths in the last three years. When pro-life policies result in more deaths, something is clearly wrong. Ultimately, implementation of the global gag rule is a huge concern for advocates of both pro-life and pro-choice agendas.

Beyond the face value of this policy lies much deeper implications on health rights and human rights. Numerous low and middle-income communities do not have the luxury of isolated family planning organizations aside from general health ones. Rural areas, in particular, often only offer integrated clinics that may offer everything from birth control to immunizations to anti-diarrheal medications. In these communities, the global gag rule may completely cut off all health care services. This not only inhibits the rights of women to make safe decisions over their own bodies, but further inhibits the ability for entire communities to access health information, resources, and services. The de-funding of generalized health centers that provide life-saving interventions not only endangers quality of life but ultimately, the right to life as a whole.

Opponents of the policy further argue that the global gag rule places restrictions on accurate medical information, and ultimately promotes the restriction of free speech (Figure 2). The increased anxiety and tension within such political climates limit open and informative discussions between providers and patients, fostering a shackled environment with limited open discourse. These violations further muddle the ability to advocate for health care rights.

The cumulative effects of the global gag rule and other policies that restrict the health rights of women are quantified through the Sexual and Reproductive Health and Rights (SRHR) Index, used to assess all US global health policies and funding that impact sexual and reproductive health rights. From 2017 to 2018, the USAID saw a drop in its SHRH score from 91.5 to 76. However, the Reproductive Rights Are Human Rights Act of 2019 was introduced by Massachusetts Representative Katherine Clark along with 142 co-sponsors earlier this month to reaffirm the goals of the 1994 International Conference on Population and Development. The Act would direct the State Department to re-include reproductive rights in its annual Human Rights Report, and potentially increase SHRH scores of significant US aid donors.

Within the global environment, research suggest that every additional $100 million in health aid is associated with a 6% increase in favorability of the United States. On the other hand, the significant reduction of international health aid by the Trump presidency may decrease American soft power over foreign governments that lack democracy and maintain poor human rights records. Pulling resources out of vulnerable regions can further cripple the stability of social climates and leave people without international advocates. The nature of political discourse, however, is always in flux, and some current cultural shifts in language differ from the present actions of the U.S. government, potentially as a response to these current events. Californian representative Karen Bass describes the slow cultural shift to a “trade not aid” mentality, in which the US should view African nations as trade partners, and to engage in more business, rather than treating the continent as solely a recipient of aid.

The future of US health aid can shift dramatically with potential changes in political leadership. Such shifts could further stifle the stable protection of human rights, particularly those of women. At its best, restrictions on aid deliver strong messages on strict protections of fetal rights to life. At its worst, these limitations can lead to far too many unintended, unsafe deaths, as well as perpetuate the human rights violations that have compounded over the long and complicated history of global health that will be discussed next month.

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If you are interested in further engaging with current discussions about global health aid and its effects of human rights, consider registering to attend the Decolonizing Global Health Conference, scheduled to take place at Duke’s Levine Science Research Center on January 31^st, 2020.

In December 2019, the Rights Writers introduced themselves and their general topic – who are the key actors, what are their goals/incentives, and what are the main debates? (How does the topic relate to human rights specifically?)

The summer after my sophomore year, I packed up my life into a duffle bag to spend two months at a rural hospital in Tanzania fixing medical equipment as a part of DukeEngage. I spent my time between the cities of Arusha and Moshi, and of course my hospital, located about an hour outside of Moshi at the base of Mount Kilimanjaro.

I wanted to immerse myself in Tanzanian culture, and I did. But I was also startled by how much of life there wasn’t exactly Tanzanian. Hubs of Westernized restaurants, internet cafes, and markets thrived on the expatriates and their guilty pleasure purchases of overpriced pizzas and colorful bracelets. More importantly, I noticed that everywhere I went, international influences had already settled into every hospital and the lives of the people who depend on them. Huruma Hospital, where I worked, had an entire outpatient clinic donated by Columbia University (figure 1), and every other hospital I visited depended to some extent on USAID funding to operate (figure 2). I slowly started to realize that the health, and thus the lives, of this nation lied in the hands of foreign aid donors. And this fact alarmed me, as I believe that the right to health is one of the most fundamental and foundational human right we have.

The right to health is fully defined as the right to the enjoyment of the highest attainable standard of physical and mental health. The right was first articulated in the 1946 Constitution of the World Health Organization, and later recognized in the 1948 Universal Declaration of Human Rights and the 1966 International Covenant on Economic, Social and Cultural Rights. Now, in today’s ever-globalizing world, it is important and necessary to understand the role international aid can play in shaping the health of a nation, and how the health of a nation can shape the rights of an individual.

Over the course of Spring semester, I’d like to address the role of international aid in promoting and protecting human rights in Tanzania, particularly at the challenging intersections of development aid and the right to health.

But what exactly is international aid? This question is definitely a difficult one to answer, and likely an impossible one to definitively quantify. International aid can range from monetary donations to nonprofit work to missionary projects to small grassroots campaigns and everything in between. In my writings, I’d like to broadly define international aid as any provision of resources by one country to another, which may entail monetary aid, physical donations, human capital, or other goods and services. Some of the largest organizations that contribute to global health aid include household names like the World Health Organization (WHO), the World Bank, the United Nations (UN), and the Unites States Agency for International Development (USAID), all of who work towards achieving the UN Sustainable Development Goal (SDG) of health and well-being.

Tanzania is a particularly interesting country to look at when considering the ramifications of global aid in promoting human rights. Tanzania is one of the fastest growing economies in Africa, and achieved its status as a middle-income country in 2018. Simultaneously, Tanzania is the second largest aid recipient in sub-Saharan Africa, after Ethiopia. Even if we look at monetary donations alone, it is often difficult to quantify how expansive aid is. USAID estimates that Tanzania has received $26.85 billion between 1990 and 2010, yet the Organization for Economic Co-operation and Development (OECD) estimates that Tanzania received $2.3 billion in aid in 2016 alone. Tanzania is currently requesting $348.41 million in aid for the year 2020, $335.11 million, or 96%, of which is intended for improving healthcare efforts. The fact is, regardless of what the exact numbers are, this amount of money is big enough to have serious consequences on a country in which half of its 57.3 million people live on less than $1.90 a day.

When 95% of local government revenue comes from either the central government or directly from donors, the role of international donors in local decision making processes cannot be overstated. At its best, this can translate into public health efforts that increase standards of living, access to water and sanitation, engagement in civil society and free media, law reform and legal aid. But at its worst, aid can run the risk of distancing citizens from decision making processes that directly influence their right to health, institutionalize human rights violations, and cripple entire nations of people.

In future blogs, I hope to explore issues such as how recent withdrawals of aid in response to anti-LGBT laws have left many HIV+ people helpless, how restrictions on aid have limited the rights of migrant working women to make decisions about their own bodies, and how international aid can help mitigate a culture of corporal punishment and forced expulsion from school as a result of pregnancy.

I had the privilege of living in Tanzania for two months and seeing first-hand how delicate human rights are amid the complex world of health. I had the choice to either feed into unproductive cycles of resource exchange or help foster a stronger culture of protected rights. Since my trip, I’ve involved myself in a research partnership with KCMC Hospital in Moshi, Tanzania and will be returning to Tanzania next summer to conduct research and continue to learn about the nation, its culture, and its people. In the meantime, I look forward to exploring the deep relationships and profound influence global health aid may have on the rights of the people of Tanzania, and how these intricacies reflect on neighboring countries in East Africa, and other low- and middle- income countries throughout the world.