Will the Trump administration sustain U.S. leadership on global health?

There are solid reasons to be hopeful that a Trump administration and Republican-controlled Congress will see the wisdom of continuing to sustain U.S. leadership in global health and that they may willingly choose to do so in concert with Democratic leaders in Congress and global health champions. That is true, notwithstanding the present uncertainty over what shape the Trump administration will take, who will fill key posts, and what the new administration’s priorities will be.

On account of presidential leadership across several administrations, U.S. commitments to global health mushroomed to over $13 billion in the past decade and a half, accounting for one-third of U.S. foreign aid and a little more than one-third of total foreign assistance worldwide dedicated to health.

These investments have translated into verifiable, concrete, historic gains: the delivery today of antiretroviral therapy to over 8 million persons living with HIV; the reduction of malaria by one-third; the near-elimination of polio; and expanded access to maternal and child health and voluntary family planning services that have contributed to healthy timing and spacing of pregnancies, improved maternal health, and healthier infants.

Child survival in low-income countries has soared, as immunizations have become more widely accessible on a mass scale. On health security and pandemic preparedness, the United States was the single-most-indispensable force in rolling back the Ebola crisis in West Africa, protecting our own people at home, and assisting to build basic preparedness capacity in those low-resource countries that have no defenses against sudden outbreaks.

The United States was the single-most-indispensable force in rolling back the Ebola crisis in West Africa.

This is a legacy in global health whose logic reaches as far back as the Reagan era, when exceptionally strong commitments were made to foreign aid as a tool to do good in the world, among the poorest and most vulnerable, and were recognized as critically important in advancing U.S. national interests.

It is a legacy of success that reaches across Democrat and Republican administrations.

It is a legacy built on an unusual oasis of sustained bipartisan cooperation in Congress even at a time of hyper partisanship, backed by a broad coalition comprised of industry, the faith community, private foundations, implementing nongovernmental organizations, advocacy groups, and universities.

It is a legacy built on durable and proven structures of quality execution, accountability, and integrity: most notably, the President’s Emergency Plan for AIDS Relief (PEPFAR) and the President’s Malaria Initiative (PMI). The same is true for key international partner institutions: the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) and Gavi, the Vaccine Alliance.

It is a legacy erected on a powerful, pragmatic consensus that guides operations and choices:

  •  Foreign partner countries have to do more on their side; they need to own the agenda, ensure their leadership is committed at the highest levels, and budget a fair share of their own resources.

  • Global health investments need to aim strategically to build enduring capacity in these countries and deliver measurable and sustainable results. Congress and the White House have to be convinced that U.S. dollars are translating into major health gains, and that U.S. national interests are served through the greater stability, prosperity, and growth of low-income countries, and through the improved standing the United States achieves in the eyes of these countries’ citizens.

  • The private sector has to be at the center of forging solutions: devising new technologies and innovative approaches, joining public-private partnerships, and investing in the delivery of health services and the provision of medicines and medical products.

  • U.S. investments have to be designed to motivate other donors to do their share. For example, every dollar the United States invests in the Global Fund—by law—is required to be matched by two dollars from other donors.

  • There is a new consciousness, post-Ebola and Zika, that health security bridges the risks we see at home with those abroad. By definition, preparedness for new and reemerging dangerous infectious disease threats has to be holistic and long term. That includes battling the rise of antimicrobial resistance, a global problem that accounts for over 26,000 preventable deaths in U.S. hospitals each year.

These achievements require high-level political will, commitment over time, and real money: through PEPFAR, the United States has invested over $70 billion since it was launched in 2003.

The picture is certainly not always pretty or merely a celebration of victories. There are still 20 million persons living with HIV who do not have access to life-saving medications, and for whom there is no clear path to meet that need. The messaging over HIV/AIDS has often been excessively optimistic, which leads to confusion that can weaken resolve. Counting the number of people still on antiretroviral therapy has proven problematic, since so many fall off treatment, and needs to be tightened up considerably. Other donors, particularly in Europe, have lately reduced their commitments, owing to austere budgets and the immense cost of caring for expanded numbers of refugees: much more active U.S. diplomacy is needed to shore up their global health commitments. But these tough challenges do not diminish the enormous gains in health in low-income countries, spurred by strategic, sustained U.S. leadership.

That’s the hopeful story, the business case for why the Trump administration needs to stay in the game. The other side of the story is more sobering: there are solid reasons to be worried that the incoming Trump administration and new Congress may turn away from the opportunity to sustain U.S. leadership in global health.

At home, there is no question we are heading into a period of intensified, bitter contestation over domestic health issues—centered on the Affordable Care Act, women’s reproductive rights, the Supreme Court, and funding of groups such as Planned Parenthood. That carries the grave risk that these escalating confrontations could spill over into deliberations over the future of international programs, including family planning and reproductive health, where the United States has led for several decades and where any support of abortion is prohibited by law.

Intensified budget pressures could make the sustainment of U.S. leadership in global health highly problematic. A massive domestic stimulus bill, combined with a significant tax cut, could result in rising deficits, inflation—and acute pressures (stoked by populist sentiment) to cut foreign aid.

An “America First” approach could also be dangerous for U.S. global health equities. A Trump administration that decides to “go it alone” in any number of areas, and in the process alienates our partners and allies, could be highly disruptive of the many far-flung global health partnerships that the United States has forged over the past decade and a half, with governments, civil society, the private sector, and the faith communities. That will be particularly true if the administration pursues a fiercely anti-Muslim posture in its immigration and counterterror policies, disinvests from UN agencies and multilateral institutions, defies international law prohibiting torture, and walks away from international alliances.

There are promising options, though. The Trump administration has within its reach several compelling opportunities that are strategic, that can leverage others to do more, that allow a large space for private-sector contributions, and that can advance U.S. national interests—and do good.

The president-elect’s daughter Ivanka Trump has shown a particular interest in woman’s health issues. Adolescent girls and young women in low-income countries are a burgeoning population, with special needs in health and development. Getting them on to a pathway to improved health and education, including safe motherhood and better economic options as adults, will provide the underpinnings for stability, economic growth, healthy families, and stronger societies. The United States is well-positioned, through its existing foundation of investments plus additional targeted programs, to keep them in schools, improve their health as mothers and that of their newborns, and secure their future as empowered, productive members of society. We have the tools to help them avoid unintended pregnancy and early marriage, space their pregnancies, prevent cervical cancer in the prime of their lives, and significantly improve their nutrition and that of their children.

We can leverage the deep and extensive U.S. investments in HIV/AIDS to significantly improve the prevention of HIV infection among adolescent girls and young women living in acutely dangerous “hot spots” where infection rates remain at staggeringly high levels.

We have the opportunity in the next four years to consolidate the elimination of polio across most of the globe, transition those programs to broader support of childhood immunization, and narrow the threat of polio in the few violent dangerous places where it is still found: Nigeria, Pakistan, and Afghanistan.

We have the opportunity to create a newly coherent U.S. approach to health security that can make Americans and the rest of the world safer from those dangerous outbreaks that are certain to occur. That will require budgeting ahead for these crises, strengthening White House oversight, and placing a new priority on battling antimicrobial resistance and new forms of resistance in TB, malaria, and HIV.

It is a legacy built on an unusual oasis of sustained bipartisan cooperation in Congress even at a time of hyper partisanship, backed by a broad coalition comprised of industry, the faith community, private foundations, implementing nongovernmental organizations, advocacy groups, and universities.

The time is ripe to turn high-level White House attention to tuberculosis. It has become the highest infectious disease killer globally, and dangerous forms of resistance are spreading rapidly. Yet for the first time in decades, the private sector is bringing forward promising new therapies and other technologies. And several countries with very high burdens—South Africa, Russia, India—are showing high-level interest in focusing anew the world’s attention upon this destructive, neglected disease.

As the Trump administration and new Congress come into power, there are high stakes for the future of U.S. leadership on global health. Special attention and care are warranted. Neglect, missteps, and errant assaults on these historic achievements could have grave consequences both for the lives of millions whose health and development prospects have improved in partnership with U.S.-led efforts and for U.S. national interests.

The U.S. institutions that drive progress forward—the U.S. Agency for International Development, the Office of the Global AIDS Coordinator (overseeing PEPFAR), the President’s Malaria Initiative—each require highly skilled, committed leadership of the quality that previous administrations, Republican and Democrat, provided, along with stable and predictable funding. The same is true for key international partners such as the Global Fund and Gavi, the Vaccine Alliance.

Even more important, the stage is set for the next administration and Congress to expand its leadership in global health in several areas, outlined above, where powerful concrete gains can be achieved and verified in the course of the next few years. With high-level political will and sustained commitment, the Trump administration could create important new legacies in global health.

Photo credit: Caitlyn Healy