Episode 8: The Responsibility of My Country in an Unjust Global System: Do No Harm

This piece is the eighth in the series “Episodes in the Life of an American, Woman, Development Economist.”  

Most of the episodes in this series have been about my luck and privilege as a white and well-off American; they reflect my growing realization that the luck and privilege I’ve enjoyed in the nearly eight decades of my lifetime are in good part a product of America’s vast wealth and power throughout those decades of the postwar era.

In this and several episodes to follow, I turn to the third theme of the series: my and my country’s responsibility to the rest of the world, and especially to the world’s poor. 

I focus not on what the US should do, but on what it should not do. What is the responsibility of my country, the US, with its vast wealth and power , to honor the central tenet of the Hippocratic oath—do not harm—in its policies and practices that affect the world’s least privileged people, the great majority of whom live in the world’s low and middle-income countries? [i]

The American body politic is more likely to acknowledge and take responsibility for past harms to other countries and peoples that are rooted in US military power than in its economic power. Compare, for example, US readiness to accept refugees from our failed military adventures in Vietnam and Afghanistan compared to our acceptance of economic refugees from around the world. Similarly, today many Americans are concerned about the harm to people in Gaza associated with US military and political support for Israel’s response to the (horrific) attack of Hamas on Israeli citizens.

But it is harms arising from US economic power and policies (trade, taxes, migration, aid, climate), that more commonly undermine the welfare of poor people in the world’s poor countries. Perhaps because economic policies are less visible than military actions (and do not directly take lives), even liberal and “progressive” Americans—my adult children, my college-educated friends, the so-called meritocratic members of the coastal elite whom former President Trump accuses of “globalism”—do not recognize their responsibility as US citizens for resulting harms, nor any responsibility to push back against those policies. (Will the climate catastrophe change that thinking among some Americans? US responsibility in that key arena is the subject of a future episode in this series.)


My wake-up to US harms

For decades I was not an exception to that absence of focus on my country’s responsibility to the world’s poor to at least minimize harms. As a development economist, I was a proponent of more aid to low-income countries, of lower tariffs on low-income country exports to the United States, of greater immigration to the US from developing countries. But I thought of these as sensible steps to further development in poor countries, at little or no cost and even some benefit to Americans, not as steps to reverse or limit harms to the billions of poor non-Americans.

Like my liberal friends, I gave (and still give periodically) to organizations that help the world’s poor and marginalized – Oxfam, Save the Children, UNICEF, CAMFED (a favorite of New York Times columnist Nicholas Kristof).

But giving is a personal decision in the realm of charity. It is not a substitute for accepting responsibility as a US citizen to be alert to, acknowledge, and try to change US government decisions and policies that bring harm to the world’s most vulnerable people beyond our borders.[ii] 

As a development economist, working at the World Bank and the Inter-American Development Bank for almost two decades, this notion of acknowledging the harmful policies of my own country did not occur to me. In those institutions, the focus at my level was not on the responsibility of the US or other well-off countries but on the responsibilities of the developing country borrowers—for better macro policies, less corruption, more attention to basic education, health, and infrastructure for their populations and so on.[iii]

That began to change when I took a job in the late 1990s at the Carnegie Endowment for International Peace, a think tank. There I began thinking about the implications for developing countries of a global system in which power and wealth are unequally shared—across countries and across individuals. With my own country at the time the widely acknowledged global hegemon, with no military or economic rival, I could hardly avoid noting how its domestic policies and its influence on international programs and policies were affecting people in developing countries.

Three examples planted the seeds of my awareness of US economic policy “harms” then—harms that were not generating awareness or political pushback at home.[iv]

Agricultural protectionism in the US (and Europe)

In the late 1990s, Oxfam (a British NGO) was fighting hard to make UK/EU agricultural and trade policy less costly to developing countries. Oxfam leaders pointed out that EU subsidies paid to dairy farmers amounted to more than $2 per day per European cow, more daily than millions of people in the developing world lived on, and led to dumping of milk on world markets, undermining livelihoods of farmers in poor countries. 

In the US, support of farmers through a combination of trade restrictions and government-supported lending enriched a few politically powerful sugar producers in Florida at the expense of producers in the Caribbean and Africa.[v]

These and other agricultural (and textile) trade arrangements, politically driven in the US by the powerful agricultural and industry lobbies, were quietly penalizing the hopes for long-term economic growth in poorer countries.[vi] Later, in 2004, the New York Times argued that African farmers were “rightfully outraged that a nation (the United States) that enjoys all the benefits of open markets for its industrial products keeps putting up walls around its farmers.”[vii]

The US pharmaceutical lobby and HIV/AIDS in Africa

As part of ongoing WTO (World Trade Organization) negotiations, negotiators in 1995 had reached an agreement on trade-related intellectual property rights (referred to as “TRIPS”) in 1995. After long resistance, developing countries succumbed to pressure to include in the TRIPS agreement 10-year patent protection for manufacturers of new medications—something the pharmaceutical firms (the Pharma lobby in the US) had pushed hard. In return, developing countries received reductions of rich country tariffs on their agricultural and textile/apparel exports—something they wanted badly, though even at the time they were unhappy with what indeed turned out to be a bad deal for them on intellectual property rights. 

By 1998, just a few years later, HIV/AIDS was killing thousands of people in southern and eastern Africa. Patent-protected prices for the new antiviral medications that were saving lives in the US and other well-off countries were unaffordable in those countries and elsewhere throughout the developing world.

So, in desperation, South Africa began importing generic versions of the new antiretrovirals from India, and Brazil began producing its own antiretrovirals—in both cases violating the TRIPS patent agreement.

What happened?  The pharmaceutical industry brought a suit against South Africa (and its president and global hero, Nelson Mandela), charging violation of the WTO/TRIPS rules. The outcome of that suit and others eventually led to amendments of the TRIPS agreement that take into account public health emergencies and allow developing countries to escape some of the more stringent rules of the original TRIPS agreement. Indeed in 2006, then former President Clinton on a visit to Africa acknowledged that he had not pushed hard enough against the Pharma lobby during his presidency.

 Similar problems with the TRIPS rules arose again during the COVID pandemic, when under pressure from Pharma the US practiced a kind of vaccine nationalism.

The war against drugs in the US

In the late 1990s, former officials from Latin America, whom I knew well after five years at the Inter-American Development Bank, were pressing the US government to decriminalize[viii] the use of cocaine, heroin, and other illegal drugs (substituting sensible recognition and greater spending on public health for police and prison spending). They believed, with good reason, that decriminalization would reduce the high street prices of drugs, helping them rid their countries of drug kings and gang wars, and of the associated corruption, threats to their democracies, and loss of life in their own countries.

Almost 15 years later, in 2012, my colleague Charles Kenny pointed out that the “addiction to a failed policy” still persisted, citing another colleague, Michael Clemens, who had written that Latin American leaders at the 2012 Summit of the Americas “were still crying out for new approaches up to and including decriminalization and regulation” of drugs in the US. In a classic case of do-no-harm warnings being ignored, US military aid to Colombia meant to end the drug war was leading to greater paramilitary violence there.[ix]


Two lessons strike me from these examples of several decades ago. First is the power of big US corporate lobbies in influencing US policies that affect the poor abroad, and indirectly harm Americans at home as well. Think sugar, and the US obesity problem. Second is the inability of US allies—at least what are mostly close US allies in Latin America in the case of US drug policy—to influence US domestic policy.

Those lessons still have bearing today.

One obvious remedy is greater exposure of Americans to such harms abroad and their roots in undue corporate power at home – especially in cases with a boomerang effect, where harms come back to hurt Americans too. The need for more exposure, especially at the relevant levels of government, makes the work of think tanks like CGD[x] that focus on US and other rich country policies that bring “harm” to the world’s poor fundamental (and also the work of journalists who turn these think tanks for insight).

Too many of America’s harms still escape the notice of most US citizens. I have hope that a new, younger generation of “globalists” (!), especially those studying and working in the field of development economics, will be more attuned to US violations of the Hippocratic oath and will embrace the responsibility—as journalists, educators, development and foreign policy experts, and as US voters—to push for the policy changes and program fixes needed if the US is to “do no harm” to the world’s poor.

A final note: The next several episodes will include more examples of US harms to the world’s poor. I welcome examples from readers (email to me [email protected]).  

I am especially grateful to Brian Webster for his substantive contributions to this episode, as well as his usual good comments on the presentation.

Comments welcome.

Email me at nancy'[email protected] if you wish to be added to a mailing list for future episodes.

Find me on Twitter:  @nancymbirdsall

[i] The oath instructs doctors and other health care workers to do no harm to their patients. Health workers are also responsible for active efforts to help their patients, with medication, surgery, or other treatments—though as with foreign aid and World Bank loans, for example, sometimes well-intentioned efforts are of little help, and generate unfortunate and unexpected side effects.  

[ii] The philosopher Martha Nussbaum argues we should all become citizens of the world rather than national citizens. “Patriotism and Cosmopolitanism”; Boston Review, 1996.

[iii] That was despite the lopsided influence of my country on those institutions (Episode 4).

[iv] For many readers this may seem like ancient history. But the fact is that 25 years later we still live with the inherent unfairness (or asymmetries) of a globalized market economy in which the gap between rich and poor countries dwarfs the gap between rich and poor citizens, and in which only some workers in rich countries prosper.

[v] These helped to make high-fructose corn syrup cheaper than sugar in the US; sugar and corn syrup both have helped to drive the increase in diabetes among Americans.

[vi] See Birdsall, Rodrik and Subramanian, “How to Help Poor Countries.” Foreign Affairs, July/August, 2005.

[vii] Quoted by CGD colleagues Todd Moss and Alicia Bannon in this 2004 publication, “Africa and the Battle over Agricultural Protection,” World Policy Journal.

[viii] In the late 1990s I participated in a Brookings Institution independent group on US policy toward Latin America that included such well-known economists from the region as Ernesto Zedillo, the former president of Mexico. The Latin economists and leaders were adamant that the group recommend decriminalization of drug use in the US. Decriminalization does not mean eliminating all regulation of dangerous drugs but instead treating such use as a public health issue rather than a crime.

[ix] Clemens was referring to research by Oeindrila Dube, a post-doc fellow at CGD. In another paper Dube showed that lack of US regulation of guns could be associated with greater violence in Latin America.

[x] See also The Atlantic Council, Brookings (sometimes), the Council on Foreign Relations (sometimes).

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