Economics

USAID has been dismantled. The World Bank's own evaluations keep finding what its projects don't achieve. So the question is no longer whether the aid architecture is broken — it's whether anything should replace it.

In the final segment of my three-part conversation with Dr. Emily Brearley — development economist, 25 years at the World Bank and other international institutions, and author of Aid Inferno: How to Reduce Poverty, Combat Global Warming, and Be a Good Person — we each put a blueprint on the table.

We agree on some fundamantal issues and disagree on some important details.

Emily's answer is what she calls Solution 42: sharply narrow what institutions like the World Bank attempt. Stick to the sectors they demonstrably do well. Build in transparency and citizen involvement in project selection and evaluation. Fund a small number of high-impact projects chosen by people in recipient countries themselves. It rhymes with Esther Duflo's evidence-first approach.

We also agree that a social contract is a fundamental missing piece — clear goals, trade-offs and obligations that people on the ground can actually hold institutions to that are negotiated. In 40+ years of fieldwork I never saw one written, and neither USAID nor the World Bank has ever framed a project in those terms. Emily agrees that's a major gap.

Where we diverge somewhat is on who does the work. Should nationals do everything, or is there a place for foreigners with unique capacity building contributions to make?

ABOUT THE GUEST Dr. Emily Brearley is a development economist and former World Bank economist with ~25 years across the World Bank and other international institutions, leading programs in Africa, Latin America and Asia. Aid Inferno is a case-study-driven critique built on World Bank evaluation data arguing that development finance rewards spending and institutional survival over outcomes and accountability.

ABOUT THE SHOW The Unpopular View is for the exhausted middle — evidence over outrage, and criticism that doesn't spare either orthodoxy. Hosted by Michael Brown, international development consultant and author of Redeeming REDD (Routledge, 2013) and Climate Mitigation in the Land Sector of the Global South (Routledge, 2026).

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I did three segments on @TheUnpopularView_MichaelBrown on the topic of sepsis with Dr. Niranjan “Tex” Kissoon, President of @GlobalSepsisAlliance. I did this because I nearly died from sepsis in June 2025—four days in the hospital, with my fever peaking at 106.4°F. Only afterward did I realize how much bigger the problem is than I ever understood, even after decades working in places where infectious disease risks in Africa and other remote parts of the Global South are rampant.

As a then‑73‑year‑old sepsis survivor who hit that high fever mark, passed out, and spent four days inpatient. At the same time, clinicians tried multiple antibiotic regimens before finding the combination that pulled me back, I’m approaching this conversation as both a patient and a policy person shaped by lived experience.

In this final segment, Tex and I look at what happens when antibiotics stop working—how sepsis turns routine infections deadly, why this is a warning sign for “superbugs,” and how the sepsis crisis exposes deeper failures in antimicrobial resistance (AMR) policy, the antibiotic pipeline, and public‑health systems in both the United States and the Global South.

From that lived experience, we move into the wider sepsis crisis in the United States. We talk through how an estimated 1.7 million adults develop sepsis each year, around 350,000 die from it, and roughly one in three hospital deaths involve sepsis—with tens of thousands of children developing sepsis and more than 1,800 dying annually.

Surprisingly, sepsis is also the number one cost of hospitalization in the U.S., driving tens of billions of dollars in annual spending and high 30‑day readmission rates. These statistics underpin an economic argument: investing in better diagnosis, sepsis care bundles, and readmission prevention isn’t charity; it’s high‑return, common‑sense policy.

Tex connects sepsis to the AMR challenge and the antibiotic pipeline problem. We outline the limited number of truly innovative antibiotics approved in recent years, the modest set of agents in clinical development that meet meaningful innovation criteria, and why companies that bring new antibiotics to market still struggle or even go bankrupt. The segment touches on major funding initiatives, the ongoing annual gap in “push” funding for early‑stage R&D, and the lack of strong “pull” incentives that reward companies for developing drugs we must use sparingly to preserve effectiveness.

Tex widens the lens to the global burden of sepsis. We discuss estimates that place sepsis in the tens of millions of cases and millions of deaths each year globally, with sepsis implicated in roughly one in five deaths worldwide and the majority of that burden falling on low‑ and middle‑income countries.

The highest sepsis burden sits in the Global South—across Africa, Asia, Latin America, and parts of Oceania—where health systems are under‑resourced and high‑tech, high‑cost solutions are least accessible. Tex and I argue that common‑sense prevention and robust public‑health initiatives—infection prevention and control, clean water and sanitation, maternal and neonatal care, vaccination, basic diagnostics, and timely antibiotics—have to be the priority for reducing sepsis deaths and slowing AMR in these settings.

We briefly reference high‑profile stories like the recent death of NASCAR champion Kyle Busch from pneumonia that progressed into sepsis, as a reminder that sepsis can move fast and affect people far beyond the ICU stereotype. But the core of the segment is Tex Kissoon’s global perspective: his work with the @GlobalSepsisAlliance, the push from @ENDSEPSIS, and his insistence that “we cannot protect ourselves without protecting others.”

Sepsis emerges here not just as a clinical syndrome, but as a pillar of global health security and a practical entry point for fixing the broken links between prevention, health systems, AMR policy, and the antibiotic pipeline.

Michael Brown concludes a three-part North-South dialogue with longtime colleague Koffi Kouakou on African realities, American assumptions, and the China factor. They examine Africa's youth surge, technology adoption, political risk, and the race between transformation and instability.

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