I.

Something uncanny happened this September. I found the TV show Friends referenced three consecutive times. First, it came up in the show Monsters: The Lyle and Erik Menendez Story, as the title of the unproduced screenplay co-written by Erik Menendez. Second, it came up in the sci-fi thriller Leave the World Behind, where a child is desperate to finish watching the show’s final episode as her family and the continental U.S. face an apocalyptic cyber-attack. Then, the BBC Global News Podcast reported that it was thirty years ago, on 22 September 1994, that Friends first aired on television. Since then, it has been a cultural zeitgeist, discovered and debated generation after generation. For some, a fond retreat to what used to be. For others, excessive nostalgia for an unrealistic depiction of life. While the show’s popularity is not unrivaled, it was the first to become such a global cultural touchstone of ‘Fukuyama-core’—the diffused expansion of ideals of American life and leadership. A proliferation of middle-class aspirations for love, friendship, family, material comfort and political predictability borne out of the insistence on post-Cold War peace and the unequivocal defeat of all ideological alternatives to liberal democracy.

Beyond the release of Friends, there is much that makes 1994 a sublime year in the annals of human history. The Genocide in Rwanda wrecked immediate and lasting devastation, trauma and violence. The end of Apartheid and Nelson Mandela’s election became a milestone for dismantling racist systems and fostering equity. The signing of the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) created a framework for subjecting life-saving drugs and medical products to the priorities of the economic powers and the rules of demand and supply. A week before Friends aired for the first time, representatives from 179 countries secured Sexual and Reproductive Health and Rights through a historic multisectoral consensus at the International Conference on Population and Development in Cairo. The conference popularized “gender equality” in public health. The Cairo conference also recognized the need to engage men and address structural assaults that compromised a fuller and healthier life for women. Despite varying motivations, this was the first time that 92% of UN members (plus the Holy See and Palestine) agreed to formally champion family planning for better health, self-determination, and interpersonal relations.

1994 played out in true End of History format, wherein human beings’ ideological evolution was reaching its culmination point, reining in the need for viable alternatives and radical revolutions. The greatest identifiable threats could be contained. The greatest viable determinants could be pursued. Conflicts and changes would still occur but within the realm of familiar variability rather than paradigmatic shifts. On this side of 1994, there are hundreds of active armed conflicts on any given day. Patent regulations and economic interest still take precedence over saving lives. Thirty years after the Cairo conference, women continue to die because of attacks on maternity hospitals or because there are simply no more health facilities. Almost all maternal deaths are concentrated in low- and middle-income countries. In the post-Dobbs U.S.A, Brittany Watts, a Black Ohio woman was charged with ‘abusing a corpse’ after she miscarried on her toilet. Amber Nicole Thurman (28) and Candi Miller (41) died because they could not secure legal abortions and timely care. Women today have fewer rights than previous generations.  

This reveals profound insights about the field of global public health – the complex constellation of multiscalar actors, policies, partnerships, and practices to prevent disease, prolong life, and promote wellbeing. Earlier this year, Daniel Krugman indicted global health for willfully ignoring the Gazan genocide, pointing to failures in research, policy, and governance apparatus in preventing and containing brutal death. Krugman finds the field governed by the same zeitgeist devoted to maintaining a U.S.-led geopolitical order and a conviction that everything can be fixed and healed within it. On this side of the looking glass, it’s our future, not our past, that feels settled. And yet, my concern transcends the decrepitude of the End of History hypothesis. It is the critical and exponential threats facing homo sapiens. Humanity is stuck in a rut. It is struggling to survive.

II.

It was clear from day one that 1994 was going to be an extraordinary year. On January 1, the North American Free Trade Agreement (NAFTA) came into effect, the Zapatista uprising in Mexico began, and in a secretive, lavish ceremony, Bill Gates married Melinda French in Hawaii. It was also the year that they established the William H. Gates Foundation, which is now known as the Bill & Melinda Gates Foundation. The Gates Foundation’s vision statement is ‘all lives have equal value’. Of course, they were not the first to espouse it. It has been enshrined in the 1948 Universal Declaration of Human Rights, which notably did not include the right to self-determination and effectively excluded large populations under European colonial control in Africa, Asia, and the Caribbean. The universality of that declaration and the claims of equality are deflated by the fact that it followed a moral, racialized, and economic imperative – not a political one. Each milestone of human civilization has been erected on grounds cleansed off categories of people who do not make the cut. A boundary is installed between those who speak on behalf of the less powerful, retaining control of the resources and circumstances to determine and declare the greater good of humanity and how best to pursue it.

This year would have marked their thirtieth wedding anniversary. Instead, Melinda French Gates announced her exit from Gates Foundation, a move that was dubbed the end of an era for the world’s biggest global health philanthropy. Several media pieces note that Melinda French Gates has been ‘getting political’ since exiting the Foundation. In the US, she endorsed Biden (and Harris, subsequently) because this time, she “can’t stay quiet”. She felt compelled to speak openly about abortion for the first time, distressed by the fact that her grandchildren will have fewer rights than her. She pledged $250 million through her company Pivotal Ventures to address women’s health worldwide. In a New York Times interview, French Gates was asked whether she spoke up on abortion too late. She responded that it was not until the Dobbs decision that she felt “there is work to do in the United States”. Now, Ms. French Gates has been the leading voice on female reproductive health at the Gates Foundation, which did not and does not fund abortion. In her book The Moment of Lift, she writes, “it wasn’t enough to speak up for family planning…I had to speak up forwomen”. Why was her decades of global leadership on women’s health and empowerment not considered a political intervention? Why did it take a threat to her own grandchildren’s future to ‘take sides’ on abortion when the majority of people, especially poor and racialized populations, and gender minorities, have battled that threat generation after generation?

There is a scarier realization at hand. How endangered is the state of women’s health if even rich white people in the United States lose the freedom to overcome primary biological vulnerabilities? This precarity is both the cause and outcome of structural flaws in how human health is parameterized and governed.  Melinda French Gates’ opinions and investments post-divorce is framed as a form of emancipation from the technical or apolitical positions of the Gates Foundation. This framing perpetuates the myth that politics is a tendency of certain people, groups, and institutions. It is considered anti-thetical to science, technical expertise, and professionalism. Politics is an inherent aspect of human life: An ongoing reflection or discussion punctuated by silences, screams, and dilemmas on how people should be treated, time should be spent, resources produced, owned and distributed. How can decisions about life and death, the control of bodily functions with dignity, freedom, and safety not be political?

Friends embodied the post-1994 ‘common ground’ conviction that sexual and reproductive rights were so secure that one need not even talk about abortion anymore. On a subreddit devoted to the show, fans discussed why Rachel never considered abortion for her unplanned pregnancy. Many defended the sitcom’s subtlety and lack of real drama. One post read: “Abortion isn’t a terribly happy subject and honestly doesn’t fit the narrative. Like the Twin towers attack wasn’t worked into the show despite it being set in New york (sic).” While termination of unplanned pregnancies can be sad or inconvenient to the plot, the fertility of all three female leads was used to advance the storyline. In fact, three episodes are named with an explicit reproductive focus: The One With Phoebe’s Uterus,  The One Where Rachel Has a Baby , The One with the Fertility Test (Monica finds out she cannot get pregnant, a temporary hiccup resolved by the unplanned pregnancy of a young girl from Ohio). This might seem pedantic, but television, media, and art are narratives that shape our values; values we affirm, accept and revisit as a social species. These morals determine what can and cannot be said; what is tolerable, comfortable, perceived as a threat to our values and our humanity.

The point is not and has never been about conflating abortion with women’s empowerment – it is but one dimension of health justice that continues to be stigmatized and prohibited by the centers and coalitions of racial-capital-patriarchal power. It is willful ignorance against bits of humanity pushed to the margins such as problems of infertility among African and South Asian people, the sexual health of transgender people, the mental and emotional health of men. And as America is set to reinstate the Global Gag Rule, cutting federal funding on abortion, remember that the original gag rule was first a parliamentary policy to disallow discussions on abolishing slavery. In our 300,000-year history, for less than 0.025% of human history have enough of us managed to agree that slavery was bad and that we might consider giving women rights. Securing humanity will always be contingent, limited and ambiguous victories. The point is that the scope, meaning and parameters of tolerable human suffering are upvoted/downvoted on narrow and exclusive platforms.

III.

In 2022, writer Ross Douthat defended Friends alongside other elements of nineties American culture that were disparaged as ‘Fukuyama-core’. Friends ran for ten years resolving much of the wayward and quirky personalities into sober heterosexual monogamy, family, parenthood, and suburbia – hell, Joey even got his own spin-off show as the good-looking, successful, single guy headed to Hollywood. An uncomplicated and relaxing TV show about shiny people with laughter tracks and happy endings comforts us so much precisely because all human life is so chock full of suffering. And perhaps that is why Ross Douthat bristled at the insinuation that the peace secured with “American normalcy… capitalism or liberalism or secularism or heterosexuality or whiteness or something else” was somehow inadequate, destructive, or obsolete.

On the eve of Dobbs v. Jackson Women’s Health Organization hearing in 2021, Douthat invoked science to defend the human rights of the embryo against abortion, “We know from embryology, in other words, not Scripture or philosophy, that abortion kills a unique member of the species Homo sapiens, an act that in almost every other context is forbidden by the law.”  What fuels the fury on abortion politics is the fact that we treat it as a team sport where the purpose is to decide whose life matters the most—The single celled zygote, the fetus, or the pregnant individual. And because we are weighing humanity on the scale of life and death, the entire political spectrum of that debate is violent. It is violent because it prevents injuries and remediable insults on a human life, shrinking the scope of how human needs can be met as a subset of what is possible. Johan Galtung makes this point in his essay ‘Cultural Violence’, where he argued that to secure peace, once must study the violence that stands in its way, just as to secure health, one must study pathology.

But a radically inclusive and humane position is typically upheld by people who need abortions. People decide to terminate pregnancies because they cannot do justice to that responsibility of parenthood or lack the mental or physical capacity to honor the child’s humanity, the resources to give them a good life, or face severe compromise to their own life by being forced to give birth. Safe abortion can be an incredibly humane decision to end potential life while safeguarding the dignity and health of an existing human life. But giving pregnant people, especially poor and non-White people, exercise that agency to safeguard their own humanity is evidently unacceptable. Abortion is neither violent nor pathological. Bans on abortion, however, are a form of violence. And we are willing to ignore and forget that fact until politicians agree or impatient optimists have a change of heart.

The 1994 Cairo conference was the last in a series of international conferences on how best to curtail ‘Third World’ populations by tinkering with female fertility. In preparation for Cairo, hundreds of reproductive justice champions and transnational feminist alliances had identified privatization, global economic crisis, and structural adjustment programs as direct threats to women’s well-being. Simultaneously, the Clinton-led US government began to use national and UN forums to articulate a “common ground”, something that would accommodate the feminist viewpoint with concerns about population growth, the environment, and economic growth.

At Cairo, delegates agreed that many nations were moving from planned economies to market economies and that this process must be assisted by the international community via training, technical assistance, and short-term supply of contraceptives. Greater private sector participation and cost-effective solutions were pushed as key solutions for reproductive health and gender equality. They agreed that females should be targeted because they were “primary custodians of family health,” and expanded access to health education and services would facilitate their traditional roles and responsibilities. The Cairo Programme of Action encouraged governments to pursue humane counseling and management of complications arising from unsafe abortions and take steps to eliminate the need for abortion—However, it did not affirm a right to abortion. This rendered sexual and reproductive health rights a contradictory compromise between very odd bedfellows—one that was bound to fall apart.

These precarious compromises are a defining feature of global health. After the mid-19^th century discovery of germ theory, the birth of transnational (now ‘global’) intervention on people’s health was born from European anxieties to control the spread of infectious diseases, especially from poor working-class people in industrial centers and racialized ‘others’ in the colonies. Commercial and colonial interests are the parents of health care – pregnancy, nutrition, sanitation, disease surveillance and containment, and the rest of it. For instance, in 1865, Britain condemned the Hajj pilgrimage from India to Arabia for spreading the cholera epidemic. But it was flexible with quarantine and isolation policies along its trade routes so that colonial exports from India would not be interrupted by disease control measures. Since colonization at its basest is a stratified exploitation and destruction of human beings, the earth and environment, anything that aids and abets that agenda could only be a pathology of power.  The cordon sanitaire of ‘health’ protects the political and economic interests of powerful elite, and it includes and excludes based on which human life is of ‘value’ to the status quo: tropical medicine for Imperialism, international health for Cold War foreign policy, global health for global capitalism.

IV.

In 2016, writer David Hopkins called Friends the ‘downfall of Western civilization’, an anti-intellectual scourge barring the romantic nerd-hero Ross Geller. Nerds, Hopkins says, should be protected, “A computer programmer from Seattle is doing more to alleviate world poverty, hunger, and disease through the Bill & Melinda Gates Foundation than any other person in America right now.” Charitable giving to ‘save lives’ has always been a part of the global public health apparatus. But in our post-1994 world, the Gates Foundation inaugurated a new era of private charity. Philanthrocapitalism explicitly draws from for-profit business practices and advances the assumption that for-profit pursuits can benefit humanity – doing well, by doing good, and dismembering the social contract between citizens and governments. Who needs the dignity and guarantee of constitutional entitlements when you can have ‘efficient’ charitable handouts?

In many ways this argument is obsolete, not least because the critique of Big Philanthropy is being appropriated by Conservative politicians and figures who defy traditional political boundaries. But it is precisely because of the dual use of a political critique that one needs to address the structural injustices at hand. Specifically, both the co-founders of Gates Foundation have moved on from philanthropy onto explicitly for-profit modes of grant making. Gates Ventures and Pivotal Ventures join the Chan Zuckerberg Initiative, Omidyar Network, and countless others to ring in the era of philanthropic investment firms – less transparency, less accountability, and more concentration of power. Everyday, new precedents are set for billionaires to fund elections and participate in foreign policy discussions. Who needs ways to evade tax payments when you can control tax policy?

This is neither an indictment of individual hypocrisy or erroneous judgment nor conspiratorial fearmongering. The Gates Foundation set a precedent by privately intervening in health and education in the US and around the world. It replicated Microsoft’s operating system for making friends and influencing people. When the US government began action against Microsoft for engaging in unlawful monopolistic practices in July 1994, Bill Gates was doing an obsequious Playboy interview that reinforced his image as the youngest billionaire and awkward yet charismatic nerd. That year, he also did a $100,000 Nat Geo photoshoot posing on hundreds of thousands of sheets of single-spaced paper, all to make a point about the storage capacity of a CD. Today, Microsoft is draining billions of gallons of global water to capitalize on AI research, including its investments in OpenAI’s ChatGPT-4 in Iowa. But don’t worry, Bill Gates offsets his carbon footprint by funding clean energy technologies and attending COP. How is private giving anything but the hand sanitizer of the filthy rich?

When someone shows you who they are, believe them. And at some level, I think most of us do. As indefensible as the anti-vax position is, there is something to be said about the essential and ubiquitous distrust we have of enormous wealth and how it accesses our bodies and our minds. The point is it need not look like microchips in vaccines. It will look like Bill Gates and Melinda French Gates getting on the phone with the German Chancellor to sway her position on explicitly prioritizing IP waivers during the Covid-19 pandemic – a decision that could have given billions of people timely access to life-saving care. Human suffering is not being reduced. It is being made more palatable.

This year, as Melinda French Gates turned 60, she did a series of interviews convening celebrity changemakers to discuss big transitions in women’s lives – ‘Moments that make us’. In one interview, Michelle Obama gushes, “Leave it to you to make your 60^th birthday a gift to other women by having these conversations.”  When she convenes female celebrities to talk about how and why ‘women matter’, Melinda French Gates still dictates the script on what matters about being a woman. Of course, we need everyone to elevate the issue, but we need not reinforce that tired chauvinism of women being ‘natural’ leaders, more honest donors, and more altruistic workers. Such ‘Women can fix it’ ideals grease the wheels of gender stereotypes, the Madonna-whore complex – only both would have a tough time getting an abortion in 41 US states and many other countries in 2024. Democrats in the US and liberals around the globe are attributing Kamala Harris’s electoral defeat to racist misogyny. Or that she was too progressive and therefore threatening to the status quo. But you don’t get to win if your administration ignores the economic pain of the electorate and runs proxy wars around the world. You don’t get to run the highest office in the world when you can’t safeguard people’s right to run their womb. Another fatal flaw of the excessive maternalization of the reproductive health agenda is the ways in which men’s health and wellbeing needs have been neglected.

You might not support abortions, but the dismantling of institutional safeguards means that you too can become dispensable if you fall through the cracks of what politicians, billionaires, technical experts consider important and interesting. Many believe that such conversations can be less belligerent. That there are more conciliatory, disciplined, and professional ways to win back rights, make a living, and convince people. Indeed, the predictability and stability of the American dream and its global offsprings feeds on the belief that social norms, laws, and the people in charge ultimately work for our benefit. And you can keep climbing that ladder until you start believing the myth of meritocracy and self-made billionaires. You legitimize where they draw the boundaries of action and inaction, us and them. And it becomes easier to gulp down the illness, poverty, and suffering of the 99%.

Human health is not a right. Rights can be given and taken away. It is the precondition for and outcome of our ability to live as interconnected, diverse, humane communities. It is an open-ended, long-term project and it will not be funded. Securing the health of each member of our species is an inconvenient, uncomfortable, and painful struggle. RBG knew that, and so did Audre Lorde. And as Vice President Harris learned on election day, we don’t always win when we fight. But we still fight to stay alive. As a people, as a species.