Study reveals distinct brain activity triggered by memories of trauma

Peer-Reviewed Publication

YALE UNIVERSITY

New Haven, Conn. — It is well known that people who have lived through traumatic events like sexual assault, domestic abuse, or violent combat can experience symptoms of post-traumatic stress disorder (PTSD), including terrifying flashbacks, severe anxiety, and uncontrollable thoughts about the incident. But what exactly happens in the brains of PTSD patients as they recall these traumatic events? Are they remembered the same way as, say, the loss of a beloved pet — or, for that matter, a relaxing walk on the beach?

A new study co-led by Yale researchers finds that the brain activity triggered by recollections of traumatic experiences among people with PTSD is in fact markedly different from that which occurs when remembering sad or “neutral” life experiences.

In the study, which involved 28 different patients diagnosed with PTSD, researchers found that brain patterns were consistent across all individuals when they recalled their more typical life experiences. But when reminded of traumatic events from their past, neural responses differed significantly among the individuals.

“When people recall sad or neutral events from their past experience, the brain exhibits highly synchronous activity among all PTSD patients,” said Yale’s Ilan Harpaz-Rotem, professor of psychiatry and psychology at Yale and co-senior author of the paper. “However, when presented with stories of their own traumatic experiences, brain activity was highly individualized, fragmented, and disorganized.

“They are not like memories at all.”

The study, conducted with researchers at Icahn School of Medicine at Mount Sinai in New York, is published Nov. 30 in the journal Nature Neuroscience.

For the study, the researchers asked each of the 28 participants a range of questions, which pertained to their traumatic experiences, events in their lives that caused sadness (such as the death of a family member), and moments when they felt relaxed. Each person’s story was written down and then read back to them while they underwent fMRI (functional magnetic resonance imaging) scans, which are used to map brain activity based on blood flow.

The researchers found that activity in the hippocampus — the area of the brain that forms memories of our experiences — followed similar patterns of activity among all subjects when they were reminded of sad or relaxing experiences from their lives, suggesting typical normal memory formation. 

But when stories about their traumatic experiences were read back to them, the similarities in hippocampal activity among the group members disappeared. Instead, the hippocampus of each subject exhibited highly individualized and fragmented activity, unlike the more synchronous patterns of brain activity during normal memory formation.

The results could explain why PTSD patients have difficulty recalling traumatic experiences in a coherent way and hints at why these past experiences can trigger disabling symptoms, the researchers say.

These insights may help psychotherapists guide PTSD patients to develop narratives about their experiences which may help them eliminate the sense of immediate threat caused by their trauma, Harpaz-Rotem said.

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JOURNAL

Nature Neuroscience

Traumatic memories are represented differently than regular sad memories in the brains of people with PTSD, new research shows

Peer-Reviewed Publication

THE MOUNT SINAI HOSPITAL / MOUNT SINAI SCHOOL OF MEDICINE

 

IMAGE: 

EXPERIENCING TRAUMATIC MEMORIES

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CREDIT: MOUNT SINAI HEALTH SYSTEM

A new analysis of the brain activity of people with post-traumatic stress disorder (PTSD) is the first to reveal that traumatic memories are represented in the brain in an entirely different way than sad autobiographical memories.

This finding supports the notion that traumatic memories in PTSD are an alternate cognitive entity that deviates from regular memory, and may provide a biological explanation for why the recall of traumatic memories often displays as intrusions that differ profoundly from “regular” negative memories for patients with PTSD.

The study, conducted by researchers at the Icahn School of Medicine at Mount Sinai and Yale University and published November 30 in Nature Neuroscience, was also the first to examine people’s real-life personal memories rather than looking at basic cognitive mechanisms, in order to link personal experience to brain function.

“For people with PTSD, recalling traumatic memories often displays as intrusions that differ profoundly from processing of ‘regular’ negative memories, yet until now, the neurobiological reasons for this qualitative difference have been poorly understood,” said Daniela Schiller, PhD, Professor of Psychiatry, and Neuroscience, at Icahn Mount Sinai and senior author of the paper. “Our data show that the brain does not treat traumatic memories as regular memories, or perhaps even as memories at all. We observed that brain regions known to be involved in memory are not activated when recalling a traumatic experience. This finding provides a neural target and focuses the goals of returning traumatic memories into a brain state akin to regular memory processing.”

Previous research has established that the brain region known as the hippocampus governs the formation and retrieval of episode memories. PTSD is associated with structural abnormalities (predominantly a reduction of volume) of the hippocampus, and impairments to hippocampal processes are focal to PTSD pathophysiology. The posterior cingulate cortex (PCC) has been demonstrated to be heavily involved in both narrative comprehension and autobiographical processing and, particularly, in emotional memory imagery. Alterations in PCC function and connectivity are specifically focal to PTSD.

To examine whether and how the hippocampus and posterior cingulate cortex differentiate traumatic autobiographical memories from sad ones, 28 participants diagnosed with PTSD underwent reactivation of autobiographical memory through script-driven imagery while undergoing functional magnetic resonance imaging (fMRI).

First, to generate stimuli based on participants’ individual autobiographical memories, the researchers used an imagery development procedure. Participants elaborated on three types of autobiographical memories: the “PTSD” condition: the traumatic memory associated with their PTSD (e.g., combat, sexual assault, domestic violence), the “sad” condition: a sad, meaningful, but non-traumatizing experience (e.g., death of a family member or pet), the “calm” condition: a positive, calm event (e.g., memorable outdoor activities).

These highly personal depictions of autobiographical memory were then systematically arranged into an audio clip approximately 120 seconds long, narrated by a member of the research staff. Notably, the PTSD and sad narratives were scripted to maximize their structural similarity to each other, to control for content and arousal. Participants listened to this novel rendition of their own memories for the first time while undergoing functional magnetic resonance imaging.

The team hypothesized that across PTSD participants, semantic similarity would correspond to neural similarity: if the personal memories of two participants are semantically close, their patterns of neural responses while listening to audio recordings of these memories should be similar as well. If traumatic and sad memories are just different cases of autobiographical memories, the researchers expected to observe semantic-to-neural correspondence across pairs of traumatic memories and pairs of sad memories alike. However, if traumatic autobiographical memories depart from—rather than being a version of—sad autobiographical memories, then they would observe the semantic-to-neural relationship only for sad, but not traumatic, memories.

The research team was intrigued to find that patterns in the hippocampus showed a differentiation in semantic representation by narrative type. In the hippocampus, sad scripts that were semantically similar across participants elicited similar neural representations on fMRI. Conversely, thematically similar traumatic autobiographical memories did not elicit similar representations.

Importantly, the researchers also found a positive relationship between semantic content and neural patterns of the traumatic narratives in the PCC, a brain region that was recently conceptualized as a cognitive bridge between the world events and representation of the self.

The study identifies a neural basis of the different subjective experience of recalling a traumatic memory as opposed to a regular memory. The data suggests that a treatment target aimed at “returning” the traumatic memory representation into a typical hippocampal representation may be beneficial.

About the Mount Sinai Health System
Mount Sinai Health System is one of the largest academic medical systems in the New York metro area, with more than 43,000 employees working across eight hospitals, more than 400 outpatient practices, more than 300 labs, a school of nursing, and a leading school of medicine and graduate education. Mount Sinai advances health for all people, everywhere, by taking on the most complex health care challenges of our time—discovering and applying new scientific learning and knowledge; developing safer, more effective treatments; educating the next generation of medical leaders and innovators; and supporting local communities by delivering high-quality care to all who need it. Through the integration of its hospitals, labs, and schools, Mount Sinai offers comprehensive health care solutions from birth through geriatrics, leveraging innovative approaches such as artificial intelligence and informatics while keeping patients’ medical and emotional needs at the center of all treatment. The Health System includes approximately 7,400 primary and specialty care physicians; 13 joint-venture outpatient surgery centers throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and more than 30 affiliated community health centers. Hospitals within the System are consistently ranked by Newsweek’s® “The World’s Best Smart Hospitals, Best in State Hospitals, World Best Hospitals and Best Specialty Hospitals” and by U.S. News & World Report's® “Best Hospitals” and “Best Children’s Hospitals.” The Mount Sinai Hospital is on the U.S. News & World Report® “Best Hospitals” Honor Roll for 2023-2024.

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JOURNAL

Nature Neuroscience

DOI

10.1038/s41593-023-01483-5 

METHOD OF RESEARCH

Observational study

SUBJECT OF RESEARCH

People

ARTICLE TITLE

Neural patterns differentiate traumatic from sad autobiographical memories in PTSD'

ARTICLE PUBLICATION DATE

30-Nov-2023

 

Despite pressures facing young families, parents take precious moments to play with their babies

Reports and Proceedings

UNIVERSITY COLLEGE LONDON

Four in five primary caregivers of nine-month-old babies reported cuddling, talking and playing with their little one several times a day, in England's first national long-term study of babies in over two decades, led by UCL (University College London). 

More than half engaged in physical or turn-taking play, singing, pretend games and noisy play with their babies several times a day – activities which were linked to improved early language development. Around three quarters showed their babies picture books or took them outside at least once a day. 

For just over one in 14 (7.4%) of these babies, most of those daily interactions will be with their father, who is their primary caregiver. Just 20 years ago, only one in 1,000 (0.11%) of nine-month-olds were cared for primarily by their dad at this age. 

The first report from the Children of the 2020s study, published today by the UK Department for Education (DfE) and led by UCL in partnership with Ipsos and the universities of Cambridge and Oxford, and Birkbeck, University of London, revealed that these home activities are having positive effects on babies’ understanding of common words, like ‘ball’, ‘bye-bye’ and ‘mummy’, as babies that played more with caregivers understood more words at this age.  

Overall, nine-month-olds understood an average of 14 out of 51 common words. This was similar to pre-pandemic norms, despite added pressure on today’s families. 

The findings also showed that parents are navigating significant challenges in their babies’ first months, with a quarter facing at least some financial strain and around a fifth reporting seeking help from a doctor for feelings of depression since the birth of their child. 

Commissioned by the DfE, Children of the 2020s is following more than 8,500 families and their babies, born in England between September and November 2021. It is the first long-term, nationally representative study of babies since the UK Millennium Cohort Study was launched more than 20 years ago. Children of the 2020s will follow families for at least the first five years of their children’s lives, shedding new light on the factors that can influence early years development. The first survey took place when the babies were, on average, nine and a half months old. 

The first findings from the study paint a picture of a new generation of infants and their families. 

Today’s parents 

• 32% of today’s primary caregivers were on parental leave from their job when their child was nine months old, compared to just 2.5% of primary caregivers 20 years ago. 
• Compared to parents raising children two decades ago, today’s caregivers are more likely to be educated to degree level or higher (50% v 33%), and employed (71% v 51%).  

Family finances 

• 25% of families with nine-month-olds had experienced significant financial strain, such as having difficulties managing finances, not keeping up with bills, being unable to afford essential baby items, and having to skip or cut the size of meals. 
• Today’s parents are less likely to own their home (50% v 64%) and more likely to rent (42% v 31%) than parents two decades ago. 
• 47% of today’s parents own their home with the help of a loan or mortgage, and 3% of families own their home outright. Among those renting when their babies were nine months, 24% rented from a private landlord, 10% from a local authority, and 8% from a housing association.  

Childcare 

• 43% of families were using some form of regular childcare when their babies were nine months. Of these families, most were using informal childcare provided by relatives or friends. However, one in eight were using formal childcare such as day nurseries or childminders. 
• Parents on the highest incomes were almost six times as likely to use formal childcare (23% v 4%) than those from the most disadvantaged homes. 

• They were also more likely to use informal childcare (40% v 31%), mainly from grandparents and other relatives and friends. 

Screen use 

• 72% of parents said their nine-month-olds spent some time watching television, videos or screens every day. On average, children who watched screens typically did so for an average of 41 minutes a day, however 7% of babies had more than two hours of screen time per day and 28% had none at all. 
• Children of the 2020s is one of the first and largest studies to measure screen time in infancy. 

Play and language development 

• At nine months, those who often played turn-taking games, like peek-a-boo, with their caregivers understood five more words, on average, than babies who did these things least. Similarly, those who were read to several times a day understood four more words, and babies who engaged in frequent physical play understood three more words, on average. 
• While the researchers caution they do not yet know whether these babies that understand more words at nine months will continue to progress more quickly, the findings are in line with other evidence that play in infancy and early childhood can improve long term language and cognitive development. 

Access to healthcare services 

• 24% of parents reported they had had trouble getting an appointment with a GP in the past 12 months, and 19% had had problems accessing a health visitor. 
• More than a quarter of mothers (26%) had used breastfeeding support services since their baby was born, with 13% paying for breastfeeding support. 

Covid-19 

• 14% of mothers had had a confirmed or suspected Covid-19 infection during their pregnancy. Between birth and age nine months, two in five babies (41%) and more than half of their parents/carers (57%) had been infected with Covid-19. 
• 74% of primary caregivers had at least one dose of a Covid-19 vaccine, and 37% of mothers had had a dose during pregnancy. 

Study director, Professor Pasco Fearon (UCL Psychology & Language Sciences and the Centre for Family Research at the University of Cambridge), said: “We are extremely excited to unveil these first findings from the landmark Children of the 2020s study, the first new national study of babies to be launched since the millennium. These vital new insights reveal the dramatic shifts in our society over that time, with fathers taking a greater role in parenting and parents more likely to be balancing caring responsibilities with work and parental leave. 

“As the first post-Covid study of families with babies, Children of the 2020s shows the many challenges parents are now facing as they deal with rising costs, health and mental health difficulties, and issues accessing public services. There are, however, very encouraging signs of resilience, with parents showing how engaged they are with creating a healthy home learning environment for their children, spending a substantial amount of time interacting positively with their babies and helping to develop their early language skills.” 

A Department for Education spokesperson said: "The department commissioned this research to better understand early childhood development factors which will help shape policy decisions. We are encouraged by many parents engaging in activities like reading and play, recognising its importance in early development. 

“Understanding the pressures many households are under, we've expanded free school meal eligibility several times since 2010, to more groups of children than any other Government over the past century. This is in addition to offering record financial support averaging £3,300 per household, implementing our transformational childcare reforms, increasing the National Living Wage, and providing help for households with food, energy and other essential costs." 

Children of the 2020s is the latest in the UK’s rich portfolio of national cohort studies, joining long-running studies of people born in 1946, 1958, 1970, 1989-90 and 2000-02, all of which are based at UCL.

• Findings from wave 1 of the Children of the 2020s (Cot20s) longitudinal study, published by the Department for Education
• Children of the 2020s study website
• UCL Centre for Longitudinal Studies
• IOE, UCL’s Faculty of Education and Society

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METHOD OF RESEARCH

Observational study

SUBJECT OF RESEARCH

People

ARTICLE TITLE

Children of the 2020s: first survey of families at age 9 months

ARTICLE PUBLICATION DATE

30-Nov-2023

Early body contact develops premature babies' social skills

Peer-Reviewed Publication

KAROLINSKA INSTITUTET

 

IMAGE: 

WIBKE JONAS

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CREDIT: ULF SIRBORN

Skin-to-skin contact between parent and infant during the first hours after a very premature birth helps develop the child's social skills. This is according to a new study published in JAMA Network Open by researchers from Karolinska Institutet and others. The study also shows that fathers may play a more important role than previous research has shown.

In current practice, very premature babies are usually placed in an incubator to keep them warm and to stabilize them during the first hours after birth. In the “Immediate parent-infant skin-to-skin study” (IPISTOSS), 91 premature babies born at 28 to 33 weeks were randomized to either traditional care in an incubator or immediate skin-to-skin contact with one of the parents. The study has generated several results that show, among other things, that immediate skin-to-skin contact is safe for babies and beneficial for their cardiorespiratory stabilization and temperature maintenance, and that it is perceived as valuable by the parents.

Now, as part of this study, the researchers have also studied the social development at four months of age of 71 of these premature babies. The children were randomly assigned to receive either standard care in an incubator or to receive care resting on one of their parents' breasts, either the mother's or the father's, for the first six hours after birth.

"What is new about our study is that we also allowed the fathers to have skin-to-skin contact immediately after the birth. In most previous studies, it is the mother who is the primary caregiver, but in our study it was the fathers who had the most skin-to-skin contact," says Wibke Jonas, midwife, senior lecturer and associate professor at Karolinska Institutet's Department of Women's and Children's Health, as well as research leader and last author of the study.

"The study has identified fathers as a previously untapped resource that really has an important function in having immediate skin-to-skin contact with their infant if the mother is not available," says Siri Lilliesköld, PhD student at the same department and specialist nurse in neonatal care, and first author of the study.

After four months, the social interaction between mother and infant was filmed and assessed by two psychologists who did not know which infant had received early skin-to-skin contact and which had not.

The quality of the interaction was measured according to the Parent-Child Early Relational Assessment (PCERA) scale, where different elements are graded between one and five, with one being cause for concern and five being very good quality.

The infants who received immediate skin-to-skin contact had significantly better results in a subscale measuring the infant's communicative and social skills. On the five-point scale, their average score was closer to four, while the infants cared for according to current practice were just above three.

"What you could see was that the infants in the skin-to-skin group had slightly better communication skills, they were a bit more social and happier," says Wibke Jonas.

Premature babies have developmental challenges as they grow up and need a lot of support. Even though medical developments have come a long way, the care of these babies still needs to be developed, the researchers say.

"If we combine the immediate medical care of the very premature babies with a relatively simple intervention such as skin-to-skin contact, it has effects on the infants social skills," says Jonas Wibke and continues.

“Previous studies have shown that premature babies perform slightly poorer when socially interacting, for example, they do not give as clear signals in the interaction with their mothers. The closeness between babies and their parents at birth may therefore stimulate later interaction and thus the development of the infant.”

The benefits of immediate skin-to-skin contact are so clear that both Wibke Jonas and Siri Lilliesköld believe it should be introduced now in Swedish neonatal care. And this work is already underway, they say.

'We have worked very actively to minimize separation between infants and parents in general, and now we have the evidence to do the same with these very premature babies,” says Siri Lilliesköld.

The research team will continue to report on the development of the infants at 12 and 24 months.

The study is a collaboration between researchers from Karolinska Institutet and the University Hospital of Stavanger, Norway, and the University of Turku, Finland. The research was funded by, among others, the Swedish Research Council, Region Stockholm and Stiftelsen Barnavård. The researchers declare that there are no conflicts of interest.

Publication: "Skin-to-Skin Contact at Birth for Very Preterm Infants and Mother-Infant Interaction Quality at 4 Months - A Secondary Analysis of the IPISTOSS Randomized Clinical Trial", Siri Lilliesköld, Karoline Lode-Kolz, Siren Rettedal, Johanna Lindstedt, Agnes Linnér, Hanne Markhus Pike, Sari Ahlqvist-Björkroth, Ulrika Ådén, Wibke Jonas. JAMA Network Open, online November 30, 2023, doi: 10.1001/jamanetworkopen.2023.44469

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JOURNAL

JAMA Network Open

DOI

10.1001/jamanetworkopen.2023.44469 

METHOD OF RESEARCH

Randomized controlled/clinical trial

SUBJECT OF RESEARCH

People

ARTICLE TITLE

Skin-to-Skin Contact at Birth for Very Preterm Infants and Mother-Infant Interaction Quality at 4 Months - A Secondary Analysis of the IPISTOSS Randomized Clinical Trial

ARTICLE PUBLICATION DATE

30-Nov-2023

 

Twin research indicates that that a vegan diet improves cardiovascular health

A Stanford Medicine-led trial of identical twins comparing vegan and omnivore diets found that a vegan diet improves overall cardiovascular health

Peer-Reviewed Publication

STANFORD MEDICINE

In a study with 22 pairs of identical twins, Stanford Medicine researchers and their colleagues have found that a vegan diet improves cardiovascular health in as little as eight weeks.

Although it’s well-known that eating less meat improves cardiovascular health, diet studies are often hampered by factors such as genetic differences, upbringing and lifestyle choices. By studying identical twins, however, the researchers were able to control for genetics and limit the other factors, as the twins grew up in the same households and reported similar lifestyles.

“Not only did this study provide a groundbreaking way to assert that a vegan diet is healthier than the conventional omnivore diet, but the twins were also a riot to work with,” said Christopher Gardner, PhD, the Rehnborg Farquhar Professor and a professor of medicine. “They dressed the same, they talked the same and they had a banter between them that you could have only if you spent an inordinate amount of time together.”

The study will publish Nov. 30 in JAMA Network Open. Gardner is the senior author. The study was co-first authored by Matthew Landry, PhD, a former Stanford Prevention Research Center postdoctoral scholar, now at the University of California, Irvine, and Catherine Ward, PhD, a post-doctoral scholar at the center.

Twin participants

The trial, conducted from May to July 2022, consisted of 22 pairs of identical twins for a total of 44 participants. The study authors selected healthy participants without cardiovascular disease from the Stanford Twin Registry — a database of fraternal and identical twins who have agreed to participate in research studies — and matched one twin from each pair with either a vegan or omnivore diet. 

Both diets were healthy, replete with vegetables, legumes, fruits and whole grains and void of sugars and refined starches. The vegan diet was entirely plant-based, included no meat or animal products such as eggs or milk. The omnivore diet included chicken, fish, eggs, cheese, dairy and other animal-sourced foods.

During the first four weeks, a meal service delivered 21 meals per week — seven breakfasts, lunches and dinners. For the remaining four weeks, the participants prepared their own meals.

A registered dietitian, or “diet whisperer,” according to Gardner, was on call to offer suggestions and answer questions regarding the diets during the duration of the study. The participants were interviewed about their dietary intake and kept a log of the food they ate.

Forty-three participants completed the study which, Gardner said, demonstrates how feasible it is to learn how to a prepare a healthy diet in four weeks.

“Our study used a generalizable diet that is accessible to anyone, because 21 out of the 22 vegans followed through with the diet,” said Gardner, who is a professor in the Stanford Prevention Research Center. “This suggests that anyone who chooses a vegan diet can improve their long-term health in two months, with the most change seen in the first month.”

Improving health

The authors found the most improvement over the first four weeks of the diet change. The participants with a vegan diet had significantly lower low-density lipoprotein cholesterol (LDL-C) levels, insulin and body weight — all of which are associated with improved cardiovascular health — than the omnivore participants.

At three time points — at the beginning of the trial, at four weeks and at eight weeks ­­— researchers weighed the participants and drew their blood. The average baseline LDL-C level for the vegans was 110.7 mg/dL and 118.5 mg/dL for the omnivore participants; it dropped to 95.5 for vegans and 116.1 for omnivores at the end of the study. The optimal healthy LDL-C level is less than 100.

Because the participants already had healthy LDL-C levels, there was less room for improvement, Gardner said, speculating that participants who had higher baseline levels would show greater change.

The vegan participants also showed about a 20% drop in fasting insulin — higher insulin level is a risk factor for developing diabetes. The vegans also lost an average of 4.2 more pounds than the omnivores.

“Based on these results and thinking about longevity, most of us would benefit from going to a more plant-based diet,” Gardner said.

The vegan participants (and the omnivores to some extent) did the three most important things to improve cardiovascular health, according to Gardner: They cut back on saturated fats, increased dietary fiber and lost weight.

A global flair

Gardner emphasizes that although most people will probably not go vegan, a nudge in the plant-based direction could improve health. “A vegan diet can confer additional benefits such as increased gut bacteria and the reduction of telomere loss, which slows aging in the body,” Gardner said.

“What’s more important than going strictly vegan is including more plant-based foods into your diet,” said Gardner, who has been “mostly vegan” for the last 40 years. “Luckily, having fun with vegan multicultural foods like Indian masala, Asian stir-fry and African lentil-based dishes can be a great first step.”

Gardner is a member of the Stanford Cardiovascular Institute, the Wu Tsai Human Performance Alliance, the Maternal and Child Health Research Institute, and the Stanford Cancer Institute.

The study was funded by the Vogt Foundation; the Stanford Clinical and Translational Science Award; and the National Heart, Lung and Blood Institute.

# # #

About Stanford Medicine

Stanford Medicine is an integrated academic health system comprising the Stanford School of Medicine and adult and pediatric health care delivery systems. Together, they harness the full potential of biomedicine through collaborative research, education and clinical care for patients. For more information, please visit med.stanford.edu.

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JOURNAL

JAMA Network Open

METHOD OF RESEARCH

Randomized controlled/clinical trial

SUBJECT OF RESEARCH

People

ARTICLE PUBLICATION DATE

30-Nov-2023

Does Germany need to rethink globalization?

Timothy Rooks Berlin

DW
22 hours ago

The current interconnected global economic system just isn't working, some economists say. They are calling for a recalculation of globalization, and what it means to be wealthy, independent, and secure.

As sand has gotten in the wheels of global markets, governments and businesses need to navigate what this means, according to Moritz Schularick

 MSC/dpa/picture alliance


Globalization has had a rough time lately. Worldwide, just-in-time supply chains suffered under stiff tariffs. COVID-19 shutdowns and travel restrictions caused further distress. Now, the war in Ukraine and sanctions on Russian companies are making matters even worse. Inflation and price increases have made energy and food more expensive. Ordinary customers, especially the poor, are suffering.

Is the world order falling apart? Is the status quo even worth saving? The world is changing, and our understanding of globalization must change, too, according to Moritz Schularick, president of Germany's Kiel Institute for the World Economy.

The focus of globalization can no longer be on squeezing the greatest possible profit from global value chains. It must also take into account "their reliability and their political implications," he wrote in a publication accompanying a discussion organized by the Federal Chancellor Helmut Schmidt Foundation (BKHS). "It will be a new world economic order compared to what we have been used to for the last 30 years, and it will challenge us."

In other words, while still enjoying many of the benefits of globalization, countries must avoid becoming too dependent on — or vulnerable to — trading with countries that are not close friends, something that Russia's war in Ukraine has shown a spotlight on.

For Moritz Schularick the main question is: How secure and independent do we want to be?

Michael Zapf/BKHS

Remaking globalization, from a German point of view

Germany, in particular, made three big bets that are not paying off as planned, says Schularick: continued growth through Chinese trade, cheap energy from Russia, and minimal defense spending under America's protective umbrella.

All three of these are coming back to haunt Europe's biggest economy now, he argues. Still, there is room for hope as Germany has great potential to improve in many areas. Importantly, it must look forward, not backward.

The lecture on December 4 at the Museum of Communication Berlin brought together a big audience to talk about the complicated issue. Schularick, who is also a professor of economics, led the discussion that focused on renewable energy, China, and closer European business integration.

Looking for solutions among problems

The time for cheap Russian gas is over. Germany and the rest of Europe must concentrate on building up renewable energy capabilities. In the meantime, new, non-Russian sources of energy must be secured to keep things running. Not only will this be better for the environment, as COP28 delegates in Dubai are currently discussing. Clean energy is also often local energy.

More complicated is Germany's relationship with China. Schularick encourages government officials to take a closer look at their foreign and security policies. They should be clearer about who are friends and who are not.

China poses a great challenge, not so much because it is so strong, but because its economy has weakened under a number of setbacks. This means fewer Chinese companies buying high-tech German exports. It also means China will likely turn to its own manufacturers as a way to grow and export its way to out of problems. This will make it a direct competitor to Germany, says Schularick. For German companies doing business in China "the fat years are over."

To counter this, Germany and the rest of the EU need to come together. This includes more digitalization, and strengthening the European Banking Union. The internal European market also needs to be liberalized and allowed to grow faster. It is a huge market, it just needs to be put to better use.

Reinventing globalization means talking about renewable energy, China and closer European integration

 Michael Zapf/BKHS

A to-do list closer to home

A single business, or even a whole branch of industry, can't make much headway alone. To make a real difference, businesses need to work with governments to plan for success, says Schularick.

This is a timely warning as many estimates about Germany's 2024 gross domestic product (GDP) growth come in at under 1%. But how can people be convinced about the need for radical change?

"I think we need a better network between academia and politics," Schularick told DW, "especially for these global issues." Precisely here he sees Berlin lagging behind locations like London, Paris, or Washington. Germany has many rules to avoid crisis, but is not prepared with crisis management skills to deal when a crisis actually arises, he says.

"We have to build up this intellectual infrastructure in Berlin, with think tanks, with media, with research and science, so that we can better anticipate what is happening in the world in the future."

Global security versus economic efficiency

This may seem a bit abstract. More concretely, a reorganization of globalization could mean having or bringing home some manufacturing production capacity to ensure supplies. It could also mean leaving behind some energy-intensive industries.

For companies, it means diversification in terms of where to produce and sell goods or services, while also securing sources of raw materials. These are all big changes that would upend decades of interdependence.

Still, Schularick is hopeful. Over the past two decades, globalization delivered on economic progress, and though it could have done better, many people enjoyed its benefits.

Yet, the world is not more peaceful or stable than 20 years ago. And it is this failure that needs rebalancing. In the future, there will have to be a tradeoff between efficiency and security. The question is: "What price are we willing to pay for less efficiency?"

Edited by Kristie Pladson

Will geopolitical tensions end globalization? 02:40


Timothy Rooks One of DW's business reporters, Timothy Rooks is based in Berlin.

Sudan crisis: Mass displacement and death

Cathrin Schaer
DW

22 hours ago

Over the past month, the conflict between two military groups in Sudan has reached what experts say is a grim turning point. The country's future is even more unclear.

The latest round of serious violence in Sudan started in April

War crimes, massacres, mass displacement and a worsening humanitarian crisis have been reported during eight-month conflict in Sudan, and many observers are now asking whether the country is on the brink of becoming a failed state or being split apart.

On Friday, the UN Security Council agreed to end its special Integrated Transitional Assistance Mission in Sudan, also known as UNITAMS. The Sudanese government had requested that the mission end because it "was failing to meet expectations."

UNITAMS was established in 2020 to support Sudan's transition toward democracy after a combination of military pressure and civilian protests succeeded in ending the rule of the country's long-running dictator, Omar al-Bashir. Instead of moving toward democracy, though, Sudan seems to be moving toward even more turmoil and violence.

There will be a three-month transitional period during which UNITAMS, which employs more than 240 people, will end its mission in Sudan

Eskinder Debebe/UN Photo/picture alliance

UN bodies operate at the pleasure of host governments and have faced more hostility in African nations recently, especially in countries such as Mali and Gabon, which have recently undergone coups. The United Nations still has other agencies operating in Sudan.

Situation is 'unprecedented'

Two major military groups inside Sudan have been fighting one another since April. They are the Sudanese Armed Forces, or SAF, and the Rapid Support Forces, or RSF.

The SAF has about 200,000 personnel and is headed by Abdel Fattah al-Burhan; it works more like a regular army. Meanwhile the RSF is estimated to have 70,000 to 100,000 personnel and is headed by Mohammed Hamdan Dagalo, better known as Hemedti. The RSF works more like a guerrilla force.

The SAF has more equipment, including tanks, helicopters and an air force, but is not as battle-hardened as the RSF.

The forces are relatively equal in terms of ability, and neither has managed to overpower the other. This has led to what the German Institute for International and Security Affairs calls a "strategic stalemate."

Darfur is still a stronghold for the RSF

Hussein Malla/AP/picture alliance

The fact that the RSF and SAF are equally strong is a result of how they were formed, experts say. Former dictator al-Bashir first created the RSF in 2013 as a counterbalance to the SAF to ensure that the military never got too strong to challenge his rule and launch a coup.

The RSF evolved from the notorious Janjaweed militias in Darfur, which were formed by fighters in Arab tribes in that area. One of the Janjaweed's main objectives was the targeting of non-Arabs in Darfur, and this has continued.

That makes the current situation "unprecedented," Hager Ali, a research fellow at the German Institute for Global and Area Studies (GIGA), told DW. "There are two military organizations that are fairly evenly matched, but that have no platform or interface between them for negotiations," said Ali, who has published extensively on Sudan. "When it comes to peace building and the negotiations, there's not much of a playbook for this particular constellation."

Months of conflict

After the end of al-Bashir's regime, the military agreed to share power with civilians until real elections could be held. That was in August 2019.

In late 2021, any transition toward democracy ended when the Sudanese military took control of the country in a coup. That included both the SAF and the RSF.

Nonetheless, negotiations about how to share power between all actors, including civilian parties, went on, even though they were very difficult. The two militaries effectively managed to exclude Sudanese civil society from national politics, Ali said.

In March, a proposal that would have seen the RSF absorbed by the SAF worsened tensions between the militaries. Growing political ambitions held by RSF chief Hemedti reportedly also played a part.

A basic framework agreement to lead Sudan toward a democratic transition had been signed in late 2022 by all military actors, including the SAF and RSF, as well as more than 40 civilian groups. It was supposed to be finalized in mid-April.

Fighting between the SAF and RSF began in April.

Sudan's humanitarian situation

Human rights organizations report a litany of grave offenses committed by the RSF since early November, including murder, rape, robbery and arson. Survivors report seeing men rounded up and shot en masse, as well as killed with axes and machetes.

Just as they have previously, the RSF has targeted non-Arabs in Darfur and, in particular, members of the Masalit community. The RSF had already driven hundreds of thousands of members of the Masalit tribe out of the area earlier in 2023.

In November, an estimated 800 to 2,000 people, mainly civilians, were killed in fighting. A further 8,000 were displaced, with many fleeing into neighboring Chad.

There are already about half a million Sudanese in Chad who were displaced by previous fighting.

An estimated 5 million Sudanese have been internally displaced over eight months of conflict

Zohra Bensemra/REUTERS

"This has become the largest displacement crisis on the continent at least, and possibly in the world," Will Carter, the Sudan country director for the Norwegian Refugee Council, told listeners last week during an online conference held by the Washington-based Center for International and Strategic Studies.

"It's a bleak situation," Carter said. "And, to be honest, we're bracing for it to get worse next year. Famine is not off the table. There are some of the worst types of atrocities being committed and very little to contain them and a collapsing state, [making] health care, education systems but also even basic banking unlikely," he added.

"The numbers are huge, funds are low, and operational capacity [for aid providers] is low," Carter concluded.

Since the latest clashes, the humanitarian situation in Sudan has only worsened. Previously there were an estimated 15.8 million people in need of humanitarian assistance, agencies say. Now, there are thought to be close to 25 million.

"The humanitarian impacts are the No. 1 reason to worry about this," Malte Lierl, a research fellow at GIGA, told DW. "It's going to overwhelm a country like Chad, and it will affect the broader region, too."

Sudan: UN alarmed at ethnically motivated attacks in Darfur  02:19

What happens next?

Some observers have suggested that the current fighting could cause Sudan to split in half, with two separate states being formed. Others think that the fighting could remain deadlocked, evolving into a similar situation as in neighboring Libya, where two halves of the country are ruled by opposing parties.

Neither the RSF or SAF wants to make any concessions toward ending the current fighting, Ali said, which doesn't bode well for a new peace agreement.

"But one of the really big things that will be decisive is each party's capacity to govern and to mobilize local people in their favor," she said.

That is where the two sides are not evenly matched, Ali noted. The SAF has most of the structures of government with it, in its base of Port Sudan. Economics will also play a role, and it will depend on who will be able to access Sudan's most important resources. In that sense, the RSF controls important territory.

Nobody really knows what will happen next, Ali said. Returning to the kind of power-sharing peace deal that existed before seems unlikely because it would force both the RSF and SAF to make too many concessions and lose personal power and wealth.

"Basically the two sides are conspiring to divide power and resources at the expense of society," Ali said.

Edited by: M. Gagnon

WHO calls for higher taxes on alcohol, sugary drinks

The WHO has called on governments worldwide to increase taxes on alcohol and sugary drinks in order to drastically curb the number of people dying from drinking and unhealthy diets.

The World Health Organization (WHO) called on governments around the world to increase taxes on alcohol and sugar-sweetened beverages (SSBs).

After studying taxation rates, the WHO said Tuesday that it believes the average global tax rate on "unhealthy products" was too low, while items such as wine are completely exempt from tax in some European countries.
Can taxes reduce deaths?

According to the WHO, 2.6 million people die from drinking alcohol and 8 million people die due to unhealthy diets every year.

The UN health agency said higher taxes would help reduce consumption of the products and incentivize companies to make healthier products.

"Taxing unhealthy products creates healthier populations. It has a positive ripple effect across society, less disease and debilitation and revenue for governments to provide public services," said Rüdiger Krech, the WHO's health promotion director. "In the case of alcohol, taxes also help prevent violence and road traffic injuries."

The WHO added that while 108 of its 194 member states already impose some taxes on SSBs, they account for an average of just 6.6% of the price of soda.

Half of those countries, the WHO noted, also tax water, which is not recommended by the UN agency.

WHO: Less cheap booze means fewer alcohol-related deaths

The WHO said minimum pricing alongside taxation could curb consumption of cheap alcohol and reduce drink-related hospitalizations, deaths, traffic violations and crimes.

"A significant body of research has demonstrated that people who engage in heavy episodic drinking tend to drink the cheapest available alcoholic beverages," the WHO said. "However, wine is exempted from excise taxes in at least 22 countries, most of which are in the European region."

Do alcohol taxes hit poorest hardest?

Globally, on average, the tax on the price of the most sold brand of beer is 17.2%, while for the most sold brand of the most sold type of spirits, it is 26.5%, the WHO reported.

While the drinks industry often cites alcohol taxes as affecting the poorest communities hardest, the WHO countered that such a view ignores the "disproportionate harm per litre for alcohol consumers in lower socioeconomic groups."

"A pressing concern is that alcoholic beverages have, over time, consistently become more affordable," WHO Assistant Director-General Ailan Li said. "But increasing affordability can be curbed using well-designed alcohol tax and pricing policies."

km/sms (Reuters, AFP, DPA)

Myanmar's displaced bear brunt of civil war

Justin Higginbottom in Sagaing, Myanmar
December 4, 2023

After the military burned down their village, one community describes their efforts to survive in a diplaced person's camp on the fringes of the jungle in the Sagaing region.

A valley in Kale Township is seen from a camp for the internally displaced in Myanmar's Sagaing region

 Justin Higginbottom/DW

Yay Chan can just see his village from the hill where he's standing on this sweltering October day in Myanmar's western Sagaing region.

In front of him are the fertile farmlands of Kale Township, nearly fluorescent green after a wet monsoon season, stretching to what remains of his home village, Yae Shin.

When Myanmar's armed forces first attacked Yae Shin, where protests erupted after the military coup in February 2021, Yay Chan said he joined a local defense force, helping to hold off the assault using a single-shot hunting rifle.

The village's resistance force numbered only around 100. When the military returned in force the next year, the resistance didn't stand a chance.

"At first, we just protested. And when the military marched into our region we defended against them. After the third clash, our whole village was burned down by the junta army," said Yay Chan.

Sagaing a 'hotbed' of resistance to military rule

The 37-year-old is now an administrator at a camp for internally displaced people (IDP).

Around 1,800 people, the majority from his razed village, live here almost totally reliant on donations. There's little work and virtually no medical care. The lucky ones have traded swathes of their family's productive farmland for subsistence farming on small plots.

A nearby forested mountain is a last refuge where residents are ready to flee to at the first sounds of aircraft or incoming artillery.

"Sometimes they [the military] kidnap people from other villages and use them as human shields to advance. Their jets also bombed our village. Families are separated and on the run," he said.

The military has razed around 75,000 homes since taking power, according to monitoring group Data for Myanmar. And more than two-thirds of those have been in the Sagaing region.

Since the coup, media often refers to this ethnic Bamar-majority region as a "hotbed" of resistance to military rule. One of the war's first battles occurred in this township.

Since then, the valley has been carved up by anti-junta forces and the military and its militias.

But away from the frontline, this camp is what much of this "hotbed" resembles — civilians struggling to survive the conflict.
Survivors struggle with physical and emotional pain

Mg Si, 39, is one of those surviving.

He and four friends took up arms against the military soon after the coup. Not long after that he was injured by a landmine. Shrapnel entered his back, paralyzing him from the waist down.

"I didn't think it would make me paralyzed. I just treated the wound with the help of my comrades thinking that I will be back on my feet to fight again," said Mg Si.

Myanmar military junta faces attacks on multiple front  02:38

He doesn't have the money to travel for treatment to a specialist in India. The major hospitals in this region have either been destroyed or are under military control.

He's left sitting out the war, spending his time under the shade of his family's one-room shelter.

"Since we are trapped here for now, I have to stay put. I don't know when it will end. Now, my wife has to take care of my needs," he said.

Mg Si said the worst part of his injury isn't physical, but rather the shame he feels for burdening his family.

They no longer have income because he can't work. He's incontinent and his wife and daughter must take care of him. His daughter can't attend school because of him. He said he doesn't know whom to ask for help. There's so few resources that make it to this camp.

As he told his story, he stared blankly into the distance. Recently his eyesight has started to fade too.

Educating children a huge challenge

If his daughter could attend school it would be in several one-room classes tucked between dense vegetation here.

Volunteers said the classes are limited in size and spread out to avoid detection by the military. Any large gathering — even a classroom — could become a target.

A nearby forested mountain is a last refuge where residents are ready to flee to at the first sounds of aircraft or incoming artillery

Justin Higginbottom/DW

At one class, Khin Sabal Phyo, 23, is teaching around a dozen primary school students. She was studying history at a university in the city of Kale when the coup happened. She left her studies out of protest.

She said she doesn't want a diploma while the military regime is in power. She's not alone. This year, the number of students who took a national placement exam for university was only one-fifth of that under the civilian government.

Now she's a volunteer, trying to teach a classroom of children without experience as a teacher or proper supplies. She said the military burned the village's school to the ground — along with precious textbooks.

The civilian National Unity Government has raised funds for education outside of the military's reach — like this classroom — but support is spread thin around the country.

Another teacher who goes by the name Rosie is leading a class of secondary students. She actually was a teacher before the war. But she joined the Civil Disobedience Movement (CDM) — a mass strike of government workers after the coup. Estimates put the number of CDM teachers like Rosie at more than 130,000.

The students here are lucky, Rosie explained. Many others can't attend because they must work to help their family survive. Others have joined resistance groups and given their lives. The World Bank says only around 56% of those aged 6-22 years are enrolled in a school.

But she said they should keep resisting where they can, even if that means organizing their own barebones education. They've lost too much to turn back now, Rosie pointed out.

Volunteers said any large gathering — even a classroom — could become a military target. This classroom in Kale Township has already been damaged.

Justin Higginbottom/DW

Camp residents worried about infiltrators

Yay Chan, the camp administrator, said they don't have weapons to defend themselves against a ground assault by the military or pro-junta militias based nearby. So they've mined the perimeter.

Even then residents are worried about infiltrators. The camp rarely accepts people who don't come from Yae Shin village.

"Our people have been suffering for years for the sake of revolution. We need food, medical supplies, raincoats and mosquito nets. I want to ask these from the [National Unity Government] so that we could endure more in the future," said Yay Chan.

The tide may be finally turning in this war. Anti-junta groups across the country have recently made gains — including in the Sagaing Region.

After nearly three years, those at this camp say they are ready for a victory. Although they can't imagine where they might find what they need to rebuild.

Edited by: Srinivas Mazumdaru

Texas woman whose fetus has fatal condition sues for abortion

Houston (AFP) – A 31-year-old woman sued the state of Texas on Tuesday in order to get an abortion for a pregnancy that she and her doctors say threatens her life and future fertility.


Issued on: 05/12/2023 -

Kate Cox, a mother-of-two from Dallas-Fort Worth learned last week that her fetus has full trisomy 18, a genetic condition that means her pregnancy may not survive until birth and if it does her baby would be stillborn or would live at most a few days

 © HANDOUT / Kate Cox/AFP

Kate Cox, a mother-of-two from Dallas-Fort Worth, learned last week that her fetus has full trisomy 18, a genetic condition that means her pregnancy may not survive until birth and if it does her baby would live at most a few days, according to the lawsuit.

Ultrasounds revealed multiple serious conditions including a twisted spine and irregular skull and heart development.

But because of the way Texas' abortion law is formulated, her physicians told her their "hands are tied" and she will have to wait until her baby dies inside her, the filing brought on Cox's behalf by the Center for Reproductive Rights said.

Should the heart stop beating, they could offer her a labor induction -- but because of her prior C-sections, induction carries a high risk of rupturing her uterus, which could kill her or prevent her from getting pregnant in future if a hysterectomy is needed.

"It is not a matter of if I will have to say goodbye to my baby, but when. I'm trying to do what is best for my baby and myself, but the state of Texas is making us both suffer," said Cox.

"I do not want to continue the pain and suffering that has plagued this pregnancy," added Cox, who has been to three different emergency rooms in the last month due to severe cramping and unidentified fluid leaks.

Cox is joined in her lawsuit by her husband Justin -- who is seeking a favorable legal ruling to assure he won't be prosecuted for assisting his wife in getting an abortion -- as well as by obstetrician-gynecologist Damla Karsan who says she is willing to terminate the pregnancy with court approval.

The Texas Supreme Court heard arguments last week in a case brought on behalf of two doctors and 20 women who were denied abortions even though they had serious -- in some cases life-threatening -- complications with their pregnancies.

The lawsuit, also filed by the Center for Reproductive Rights, argues that the way medical exceptions are defined under the conservative state's abortion restrictions is confusing, stoking fear among doctors and causing a "health crisis."

The Texas Supreme Court is expected to soon issue a decision whether to block the state's abortion bans in cases such as Cox's.

The US Supreme Court overturned the constitutional right to abortion in June 2022.

A Texas state "trigger" ban went into immediate effect, prohibiting abortions even in cases of rape or incest. Texas also has a law that allows private citizens to sue anyone who performs or aids an abortion.

Texas physicians found guilty of providing abortions face up to 99 years in prison, fines of up to $100,000 and the revocation of their medical license.

© 2023 AFP

'Sleepwalking into dictatorship': Trump warnings spook America

Could a second Donald Trump presidency slide into dictatorship? A sudden spate of dystopian warnings has got America talking about the possibility less than a year before the US elections.


Issued on: 06/12/2023 -

A rash of dire warnings has appeared in US media that a second Trump presidency could slide into dictatorship 

© Brandon Bell, Getty Images North America via AFP

By: NEWS WIRES

Dark scenarios about what could happen if the twice-impeached Republican former president wins in 2024 have appeared in the space of a few days in major US media outlets that include The Washington Post, The New York Times and the Atlantic.

Grim predictions also came from top Republican Trump critic Liz Cheney, who said that the country is "sleepwalking into dictatorship" and that she is weighing a third-party presidential run of her own to try to stop him.

Together, they paint a bleak picture of an angrier yet more disciplined Trump than during his first spell in the White House, one who would wreak vengeance on his perceived enemies and possibly try to stay in power beyond the two-term US limit.

President Joe Biden, who faces a rematch of his bitter 2020 contest with Trump, said the warnings backed his own claims to be defending US democracy.

"If Trump wasn't running, I'm not sure I'd be running. But we cannot let him win," the 81-year-old Democrat told a campaign event in Massachusetts.

Biden cited Trump's own increasingly violent language on the campaign trail, saying his rival's description of his opponents as "vermin" echoed the language used in Nazi Germany.

"Trump's not even hiding the ball anymore. He's telling us what he's going to do."
'President for life'

Trump, 77, and his allies have responded as they usually do, by fighting fire with fire. He accused Biden of himself being a "destroyer of democracy" and even reposted one of the most critical articles on social media.

Trump has called political opponents 'vermin' 

© JOSEPH PREZIOSO / AFP

Conservative Fox News described it as "media panic", while pro-Trump Republican senator and author J.D. Vance said on X that "everyone needs to take a chill pill".

But the sudden uptick in warnings -- against a backdrop of Democratic angst over polls showing Trump now leading Biden despite facing multiple criminal trials -- has been striking.

The most eye-opening piece appeared in The Washington Post by conservative commentator Robert Kagan, with the headline: "A Trump dictatorship is increasingly inevitable. We should stop pretending."

Comparing him to the power-grabbing Roman emperor Julius Caesar, the lengthy article says neither the US Constitution nor the Supreme Court could prevent Trump being "president for life" if he wanted.

Kagan wrote that if Trump survives the trials he faces over trying to upend the 2020 election and cling to power illegally, and wins the next election, he will in effect feel he is above the law and can get away with anything.

The New York Times analyzed the ways that a "second term could unleash a darker President Trump" than in his chaotic first presidency from 2017-2021.

Trump has "spoken admiringly of autocrats for decades" and would likely follow their example by packing the civil service with loyalists and using the Justice Department to crack down on opponents, it said.

In scenes reminiscent of a dystopian movie, it said Trump would also set up migrant detention camps and use the military against protesters under the US Insurrection Act.

The Atlantic magazine meanwhile is dedicating its entire January-February 2024 issue to what a Trump presidency would look like, with an editor's note titled simply: "A Warning."
'Dangerous moment'

Some of the most dire forebodings have come from Cheney, the former Republican lawmaker and daughter of ex-vice president Dick Cheney, whose opposition to Trump made her a pariah in the party.

Trump supporters stormed the US Capitol after he lost the 2020 election 

© Olivier DOULIERY / AFP/File

"It's a very dangerous moment," she told NBC on Sunday.

There was "no question" Trump would try to stay in office beyond 2028, she said, adding that the January 6, 2021 assault on the Capitol by supporters trying to overturn Biden's election win was merely a "practice run."

For his critics, Trump's autocratic side has long been in plain sight.



Trump already faces trial for conspiring to upend the 2020 election result, with prosecutors saying on Tuesday that evidence shows he was determined to "remain in power at any cost."

His language has turned more extreme in recent months, during which he described migrants as "poisoning the blood of our country" and suggested his former military chief should face death for treason.

But in the looking-glass world of Trump and his allies, he is always the victim.

"Joe Biden is the real dictator," Trump said in a picture posted on his conservative Truth Social network.

(AFP)