A new global order, for better or worse

Learning from a changing world.

The past two months have brought dizzying changes to many aspects of the world, disrupting much that we may have once believed were largely settled, stable. We have seen changes come to “the post-war global order,” where the US is a core part of NATO, closely aligned in its interests with Europe, forming a unified bloc that pushed back on Russian expansionism. This unity is now in doubt as the US appears—in the rhetoric of President Trump at least, and in that of some members of his administration—to have changed how it thinks about both Russia and about its commitments to long-held European allies. Moving domestically, assumptions about the solidity of federal employment have been upended, as have the country’s investments in, among other areas, global aid, a belief in scientific research as a national asset, and, potentially, an understanding of a social safety net that reflects a shared social compact.

These few sentences do not fully capture the scope of the changes we are seeing or the likely consequences of these shifts in the “order of things.” I have written before that we should aspire to give space for alternative visions of what the country, and the world, might look like even as we have a responsibility to call out the cruelty of intemperate action. But today, I wanted to reflect on the fundamental shift in the global and domestic order, and, centrally, what it means that we are going through such a moment, and how we might respond to it.

The existing world order as of a few weeks ago was in many ways an enormously positive force in the world. Under the post-war global order, the world avoided large-scale conflicts. It fostered the growth of democracies and was accompanied by a period of remarkable increase in prosperity and a lifting of people from poverty, a rise in living standards which did much to improve health. The percent of the global population living in extreme poverty declined significantly—from about 58 percent of the global population in 1950 to about 9 percent in 2018. Democracy has also been ascendent during that time. In 1940, 78.2 percent of countries were closed autocracies and 4.1 percent were liberal democracies. In 2024, 17.3 percent were closed autocracies and 16.2 percent were liberal democracies. The period also saw a growth in global literacy. In 1940, about 58 percent of the global population was illiterate. By 2023, that number had fallen to about 13 percent. In other words, this historical period was, in many ways, the best of times.

It is important to note, however, that the existing world order as of recently also had much about it that was not working well. Under the post-war global world order, a small group of countries, many of them built on colonial traditions, continued to dominate international trade and wealth. The post-war era has been a time of growing economic inequality, with the world’s richest one percent owning nearly half of all the world’s wealth in 2023. While economies flourished in rich countries, they faltered in many other places. Among many countries that were formerly in the Soviet bloc, for example, growth has been significantly slower than in Western Europe. While health has flourished in rich regions, with life expectancy rising, for example, to 79 in Europe and Oceania, it remains worse in poorer regions, with life expectancy rising to just about 64 in Africa. Such inequality is also present in the US. Since 1979, wages for middle-wage workers have stagnated and wages for low-wage workers have declined, while wages for those with very high wages have significantly increased. Nationally, economic inequality has driven health inequality, with the richest American men living 15 years longer than the poorest, and the richest American women living 10 years longer than the poorest. There is also wide variation in health by region, with high life expectancy in some states (Hawaii: 80.7, Washington: 79.2, Minnesota: 79.1) and low life expectancy in others (Mississippi: 71.9, West Virginia: 72.8, Louisiana: 73.1). In other words, the post-war global order was, in many ways and in many places, the worst of times.

The fundamental point I am trying to make is that how we perceive the utility of—and, as such, the importance of—the existing world and domestic order, depends very much on how we measure progress and the lack thereof, and I would venture to guess that how we measure progress depends primarily on where we have been sitting at the table. If we are in a place where we have been reaping the benefits of progress and change, be that globally or domestically, we may feel quite differently about how committed we are to preserving the current order, or to fighting changes to it. We may be quite fearful of the changes of the moment, or welcoming of them, depending on whether we are gaining or losing in the existing world order. There is nothing particularly new about this notion—we all operate from within biased frameworks, and it is very hard for us to recognize that others may not be benefitting when we are, or, conversely, that when we are not benefitting, others may be. A classic example of this, which has long been part of the conversation, but has seen its profile particularly elevated in the Trump era, is that of global free trade and the subsequent deindustrialization of America as manufacturing has moved overseas. The argument for this has always been that, by making goods cheaper, free trade creates a rising economic tide that lifts all boats. There is much about this argument that is compelling, and the economic benefits of free trade have indeed brought higher living standards to many, improving lives and health. However, free trade has also created deep inequalities, as many people and regions that relied on manufacturing have found that the economic rug has been pulled out from underneath them. Their discontent with this, and with the seeming inability of mainstream politicians to do anything about it, has been a significant factor driving the rise of Donald Trump, enabling many of the disruptions we are now seeing.

That brings me, then, to the moment. I am continually engaged in conversations about the challenges posed by the developments of recent months. I have made my professional career for the past 25 years in universities that are now being challenged like never before. It is very hard for me to see past these challenges, to see the moment as anything but threatening. But, separate and apart from the simple fact that more than half the country voted for enormous change, one needs only to look at half of the media—the half that I seldom read, and that I think most people I speak to seldom read—to recognize that the moment is, at least for now, being greeted with thinly disguised glee by many, perhaps even by half the country. Even globally, although we are surrounded by concern—reasonable concern, to my thinking—about the apparent collapse of the US/European alliance, that alliance is not being mourned by India and China, where about 35 percent of the world’s population lives. It is also true that when old orders fall, new orders rise, and they are not always worse than what came before. But the transitional period is often tumultuous, and if we are indeed in the foothills of such a historical moment, the proper attitude to embrace is surely one of wariness.

What are we to make of all this? Centrally, that those of us who have benefitted from a particular global or domestic order are not too happy to see that order change. This is, of course, quite a different matter for those who have not so benefitted from the recent status quo. An analysis that I frequently cite, conducted by Professor Jacob Bor, showed a direct correlation between health in US counties and vote for then-candidate Trump in 2016—a protest candidate, one who promised to rip up the playbook and start over. Similar analyses have shown votes for populists negatively correlated with health in European countries. None of this is particularly shocking. If you are not doing well, are you going to mourn things changing, or are you going to feel you have nothing to lose and be more than happy to endorse change, even if, perhaps especially if, it is pronounced and dramatic?

I am not blind to the fact that some aspects of the current moment of change are also being cynically driven by those who were doing well and who, with some of the changes being put in place, stand to do even better. However, I would contend that, nevertheless, the changes we are seeing would be unsustainable unless there was a genuine base of public support for them, one that is driven by a sense that dramatic change is a good thing, be it change on cultural issues or on economic issues.

What can we learn from this moment? I suppose what I take from it is that we need to work to ensure that there are no left-behinds when times are good, to make sure that good is shared evenly by the many. It is perhaps an irony of this moment that public health has long focused on addressing inequities, placing concern for health have-nots at the heart of all we do, yet as we have done so we have found ourselves, as a discipline, becoming more and more distanced from these left behind populations, to such an extent that they now associate us with the class of so-called “elites” that ought to be seriously disrupted in this moment. It is worth having conversations about how this happened, including about the role of the language and symbols we embrace. The Healthiest Goldfish has, hopefully, been a place where such conversations can take place. If we do indeed represent the status quo that so many rage against, we should do all we can to ensure there are no legitimate reasons for this anger, redoubling our focus on improving the health of all, so that the next time voters are given a choice between stability and disruption, they will choose stability, confident that the stewards of stability are invested making sure that all can share the benefits it yields.

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Also this week

Thoughts in the European Journal of Public Health on shaping a vision for the future of public health based on the integration of data, core values, and engagement with emerging challenges and opportunities.

An editorial in JAMA Health Forum on the journal’s progress over the past year.

Commentary with Mohammed Abba-Aji in Psychiatry, “Integrating Population Health Science and Systems Thinking into Suicide Prevention.”