The outbreak of COVID-19, with staggeringly high numbers of cases and deaths both domestically and globally, is already causing policymakers to initiate a post-mortem on how the global and domestic response went wrong. One lesson is already clear: disease knows no borders, whether it’s COVID-19, Ebola, HIV/AIDS, tuberculosis (TB), or malaria. “Lockdowns” and social distancing instituted by responsible authorities within national borders have been important, even in the European Union, showing that the role of sovereignty still pertains. However, it is essential to look beyond borders.
International cooperation is imperative in fighting pandemics and promoting global health, and the United States has large stakes in providing catalytic leadership. If HIV/AIDS and COVID-19 have taught us anything, it is that “health security” is indeed really a security priority. Moreover, improvements in human capital through health and education are associated with faster economic growth, which in turn spurs long-term stability. And much beyond these benefits, U.S. leadership on global health also offers a “soft power” asset in its reputation and diplomacy.
Whoever is President in January 2021 would do well to follow a five-part playbook for re-establishing leadership in global health. All five steps bridge U.S. interests and values, aim to walk with rather than dictate to partners, and scale up pronounced U.S. comparative advantages.
Priority #1: Scale Up Global Health Security
The COVID-19 pandemic, while far from over, has already provided one signal lesson: preparedness is key. While preparedness is critical at the local level—like hospitals, clinics and community workers having a pandemic contingency plan—it is even more essential at the highest levels. A global health security agenda in which governments substantially invest in long-term global health capacity will prevent a crisis of the scale of COVID-19 from happening again.
Before, say, the spring of 2020, few might have conceded that “global health” could be categorized as a matter of “security.” But that is precisely how we must understand it. Investing in global health security will help protect Americans by containing and controlling epidemics at their sources. Extending efforts by the U.S. Agency for International Development (USAID) and The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) to bolster health systems reduces the risk of Americans and military personnel contracting diseases overseas, and can also prevent the destabilizing spread of those diseases. It’s crucial to look beyond short-term measures—like social distancing or scrambling to develop tests, therapeutics, and vaccines—and move toward long-term, sustained investment. All these measures require international cooperation facilitated by a collaborative form of U.S. leadership.
The United States witnessed the importance of health security during the Ebola epidemic of 2014. Despite non-profit and public sector efforts, the disease spread across borders, with fear and misinformation not far behind. Chronic lack of domestic investment in health systems left many nations vulnerable, with global repercussions. Extending low- and middle-income nations’ capacity for preventing, detecting, and responding to emerging threats is not just a necessary insurance policy for them—it is for the United States, too.
In the wake of Ebola, the Global Health Security Agenda (GHSA) under the Obama Administration allowed the United States to lead partnerships with other nations and public-private stakeholders to prevent, detect, and respond to infectious disease threats. This initiative elevated global health security to a national priority. Before COVID-19, the Trump Administration cut White House personnel and budget requests committed to it, while nonetheless issuing (but not implementing or resourcing) a Global Health Security Strategy calling for bolstering global health infrastructure, international resilience, and national defenses against biothreats. Since COVID-19’s onset, rather than engaging to improve an imperfect and donor-influenced World Health Organization (WHO), the administration has sought to just work around it. The WHO has been criticized for its handling of the COVID pandemic and its apparent catering to China’s agenda. Yet it’s important that we work with and seek reform from the WHO as a unique source of surveillance information and guidance, rather than reject it altogether.
Washington needs to take advantage of existing health institutions and partnerships. It should use the most nimble and reliable among them—such as the aforementioned Global Fund, which integrates private sector and community-level capacities and has built resilient health systems to overcome the three most deadly and emerging pandemics. (Full disclosure: I am Chief Policy Officer for a non-profit advancing the Global Fund’s mission.) Enjoying existing financial relationships with other institutions like the World Bank, the Global Fund invests in community systems that fight stigma, support volunteers, raise awareness, and improve access to health services, treatment, and care. The Global Fund grants approximately $1 billion per year in sustainable health system development, which is more than any other multilateral institution, and Georgetown University researchers have demonstrated that 37 percent of Global Fund investments extend health security capacity. The U.S. government should improve and revitalize these existing assets, rather than inventing new systems and organizations from scratch. The early life of the Department of Homeland Security as post-9/11 creation is a cautionary tale about the unintended consequences of creating institutions in crisis moments.
By scaling up partnerships that work, the U.S. government can deepen steps vital to health security: the creation of sustainable healthcare systems, the training of health workers, the improvement of procurement methods and supply chain management, the strengthening of diagnosis and detection techniques, and the empowerment of community voices and implementers as much as health ministries.
In addition, a new Global Health Security Challenge Fund could fill gaps in resources and technical assistance among fragile nations. Senators James Risch, Robert Menendez and Chris Murphy are among those introducing legislation exploring such a trust fund. Senator Murphy rightly observes: “Our health security in the United States is no stronger than the weakest country’s public health system.” Flexibility should be maximized and redundancy minimized in any additions to the global health institutional landscape.
Priority #2: Apply a Human Rights Lens to Health
Health is not only about security, it is also deeply intertwined with human rights. Three of the world’s most fatal communicable diseases—malaria, HIV/AIDS, and tuberculosis—disproportionately affect poorer populations. This disparity is often compounded by other factors—like gender, sexual orientation, youth, or migration status—in ways that particularly affect marginalized or stigmatized populations. Moreover, the data collection systems imperative to successful and constantly refined health interventions are often ill-equipped to capture data on these groups (though recent reporting has offered a glimpse of the racial disparities of the pandemic here at home).
Marginalized groups are also particularly vulnerable to violations of human rights, which it has long been a priority of U.S. foreign policy to curb. If the United States is committed to the meaningful freedom and dignity of all, then availability, accessibility, and quality of health care for socially and political marginalized groups matter. Discriminatory policies limiting access to health care prevent upward mobility and the freedom to thrive. Whole groups at home and abroad are left hamstrung from contributing to the world economy, squandering human assets that benefit the United States. Targeted investments to spur better access to health abroad are neither a blank check nor sheer altruism.
Health is an enabler of opportunity, most notably for females. A new health agenda could expand on the Trump Administration’s Women’s Global Development and Prosperity (WGDP) Initiative, which enjoys striking bipartisan support. By increasing women’s access to quality education, training, and lending, such programs provide opportunities for higher-paying jobs and entrepreneurship that improve local economies. But if young women lack the ability to time and space pregnancies, or access to preventive measures against HIV infection, it inhibits well-intentioned initiatives for their economic empowerment.
Priority #3: Prioritize Governance and Country Ownership
U.S. global health policy should also put governance front and center. More often than not, democratic governance and better health are mutually reinforcing—a virtuous spiral up.
It is true that not all democracies have performed equally well in response to our current pandemic—compare the success of South Korea to the comparative failure of Sweden. And it is true that other variables like social trust, political culture, and state capacity play into the equation. But all else being equal, democracies involve mechanisms of accountability that make them more responsive to health threats than their autocratic counterparts.
What’s more, investments in better health fuel better governance. As shown in a study by Matthew Kavanagh and Lixue Chen published in the Annals of Global Health, “increased Global Fund financing is associated with better control of corruption, regulatory quality, voice and accountability, and rule of law.” That means that U.S. global leadership on health is an investment in better and more democratic governance abroad, with all its accompanying benefits.
The more transparent, inclusive, and accountable governance is, the more likely health needs and threats will be addressed. Between 1980 and 2016, according to one study, the “democratic experience” of a nation—an indicator of how democratic a country has been and for how long—was more responsible for reductions in mortality from noncommunicable diseases than GDP, urbanization, or the amount of international aid. According to Thomas Bollyky of the Council on Foreign Relations, a 1 point increase in the “democratic experience,” for example, corresponds to a 2 percent decrease in deaths from tuberculosis. Democratic governments are open to sharing of health information, accepting of feedback from constituents and interest groups, and more responsive to improving the quality of government health-care services than less democratic governments.
The contention that democratic governance facilitates better health care faces a nettlesome test case in the United States and China. Despite challenges with containing COVID-19 in the United States, the positive effect of our open governance compared to the authoritarian Chinese model is still apparent. China’s pandemic response has used COVID as an opportunity to expand surveillance and strengthen control over dissidents, reflecting its authoritarian system. Dr. Li Wenliang, a Wuhan-based doctor punished by the Chinese police for warning other doctors about the virus’s deadly impact, is emblematic. For all the failures of a particular president, the far more transparent U.S. political system holds promise for self-correction and renewal, by keeping policymakers accountable.
No less important than democratic accountability is country ownership of health policy. This entails countries forming their own health strategies, with civil society having a major voice and implementing role along with states, and domestic resource mobilization emphasized in addition to foreign donations. Despite COVID-19 buffeting developing countries’ economies, a tide is rising in Africa and other developing regions’ capacity to invest in their own people through health. Tailoring and leveraging international assistance to stimulate domestic resources is wise. The Global Fund’s sustainability and transition policy, for instance, requires funding recipients to put their own skin in the game (at the risk of holding back funding, as it did with Nigeria four years ago), and uses catalytic grants to incentivize countries’ own allocations for priority areas. U.S. bilateral and multilateral efforts should prioritize country ownership—not to wash our hands of helping the most marginalized, but to build sustainability and socially inclusive decision-making. Ultimately, even more important than who shall pay is who has say: countries themselves, including civil society and affected communities.
Priority #4: End the AIDS, TB, and Malaria Epidemics
Since the George W. Bush Administration, the U.S. government has embraced a bipartisan-supported mission to end the HIV/AIDS, tuberculosis, and malaria epidemics. The consensus is reflected in bilateral programs like the President’s Emergency Fund for Aids Relief (PEPFAR) and the President’s Malaria Initiative (PMI), and robust support for the Global Fund since its founding in 2002. As of 2019, 18.9 million people were on antiretroviral therapy for HIV, 5.3 million people with TB were treated, 131 million mosquito nets were distributed and a total of 32 million lives saved by the Global Fund and its partners.
HIV/AIDS may be the most well-funded of the responses to these three diseases. The AIDS movement in the mid-1990s, spearheaded by people living with AIDS, innovative activists, celebrities, and political leaders, led to a concerted global response including sustained (if not wholly sufficient) funding being dedicated to relieving the burden of the disease. The development of anti-retroviral treatment, allowing those with HIV/AIDS to escape the previous death sentence it represented, and the inclusion of HIV in the original Millennium Development Goals propelled progress.
The fight against tuberculosis (TB) had a similar impetus, with health leaders, heads of development agencies, and G7 countries partnering to eliminate the disease. Tuberculosis was declared a global emergency in 1993 for which the International Union Against TB & Lung Disease (“The Union”) created a new treatment model that was adopted by the World Health Organization (WHO). A quarter century later, a High-Level Meeting of the UN General Assembly in September 2018 committed world leaders to stepped-up efforts, although only some trailblazers like India and Indonesia have markedly followed through.
With less civil society activism than the movements combatting HIV and TB, malaria is an epidemic requiring more political momentum. Programmatic focus at the Abuja Summit in April of 2000 resulted in 44 African nations agreeing to reduce malaria mortality by 50 percent in 10 years. Partnerships like Roll-Back Malaria (RBM), the Gates Foundation, The Global Fund, and the President’s Malaria Initiative (PMI) launched by Bush have mobilized resources and innovation in preventive bed nets and spraying. Remarkable progress has been achieved; 21 countries were on the road to near malaria eradication by 2020, although efforts have been heavily disrupted by coronavirus.
Complicating the fight against the three diseases is collateral damage from COVID-19 on health supply chains, prevention, and treatment programs. According to a recent Global Fund report, three quarters of programs to prevent these three diseases are facing disruptions due to COVID-19, which would set back efforts to eliminate the diseases by decades. Analyses from Imperial College London, UNAIDS, the Stop TB Partnership, and others suggest the annual death toll across the three diseases could nearly double this year as health systems and communities are overwhelmed, treatment and prevention programs are disrupted, and resources are diverted. Absent U.S. and collective action, COVID-19 could bring a return to mortality and incidence rates in HIV, TB, and malaria not seen since 2007, squandering past U.S. investments in epidemic response and so many potential-filled lives.
The Sustainable Development Goals aim to end these three epidemics by 2030. Failure to scale up methods that have saved tens of millions of lives in the last two decades threatens to squander the investment to date and risks the three epidemics’ resurgence. As COVID-19 is going to be a major challenge to brittle health systems, global health institutions must find ways to fight COVID-19 and HIV/AIDS, TB, and malaria simultaneously. That’s why the Global Fund created a new mechanism that assists countries fighting COVID-19 through its accountable existing partnerships and channels, while at the same time shoring up efforts to continue progress against HIV/AIDS, TB and malaria. We can and must finish the job on three signature aims of U.S. leadership.
Priority #5: Innovation
Innovation is pivotal to global health, and one the United States is poised to leverage with its research prowess and market creativity. Consider the Ebola vaccine, Ervebo, a FDA-approved breakthrough for prevention. A lab in Winnipeg, Canada was working on the vaccine but was unable to make much headway due to a lack of interest from the WHO or pharmaceutical companies. However, after the outbreak in West Africa in 2014, Merck purchased the research and began development. U.S. and European regulatory agencies gave approval very quickly to ensure the vaccine was available for all who needed it. Furthermore, WHO prequalified it for faster approval in African nations and GAVI, the vaccine alliance, launched an emergency stockpile for future outbreaks. Public-private partnerships and an effort to leaven and loosen bureaucracy contributed to efforts since 2014 to contain an emerging pandemic.
Innovation is not a straight path. For instance, NIAIDS’s HVTN702 HIV vaccine trial in South Africa was halted after findings of non-efficacy, despite high safety rankings. But leveraging innovation requires a patient and strategic rather than reactive approach. As such, innovation in global health is not limited to infectious diseases; for instance, WHO prequalified new vaccines to combat typhoid and rotavirus, the most common causes of severe diarrheal diseases in children subject to poor sanitation.
Given the impact of COVID-19 on other health conditions, innovating to leapfrog over longstanding practices is wise. Social distancing measures have forced people undergoing TB treatment to start multi-month medication regimes and discontinue in-person observation and patient support in favor of logging their doses on social media. COVID-19 aside, innovation to simplify current arduous treatment regimens is welcome, as many patients often prematurely drop out of them once they feel better, allowing tenacious drug-resistant strains of TB to grow. Further, scientists at the CDC have recently created a recency test which rapidly tests for both HIV and COVID simultaneously, shedding light on the timing of exposure, which is critical to contact tracing.
The innovation imperative is highlighted by both the immediate needs to develop tests, therapeutics, and a vaccine for COVID-19 as well as the needs for better interventions to address the many longstanding health threats the pandemic exacerbates. The United States has an innovation comparative advantage highly valuable to its humanitarian, economic, and security aims. Alternatively, contemplate the implications of China developing a COVID-19 vaccine first and leveraging its dissemination for influence. To accelerate and then deploy innovation, it is much better that the United States play the role of leader and catalyst than other great powers less attached to mutual benefit and open governance.
The U.S. government needs to boost research and development to build that comparative advantage. We should create a new Office of Cures Research at the National Institutes of Health, expanding on the 21st Century Cures Act which funded the Cancer “moonshot” initiative. It should bolster the recently formed Africa CDC by working closely with the African Union and multilateral stakeholders. An increased level of funding for the National Institute of Health, young scientists and research networks in Africa and other resource-limited settings would have a multiplier effect on health outcomes in those settings.
Conclusion
In truth, we already have many tools and resources necessary to confront global health challenges. Existing infrastructures like the Global Fund can be leveraged to help countries build health systems and prepare for unexpected challenges, like COVID-19. New arrangements, like a Global Health Security Challenge Fund, will add value if they don’t duplicate but incorporate the nimblest among existing programs. We must demand more from our much-needed institutions, like the WHO, and offer alternatives for corrosive models, like China’s, when we see them offering health solutions that are not accountable, transparent or inclusive. Leveraging the best of what exists, renewing essential but imperfect assets, and creating new partnerships which add value requires international cooperation and coordination. The United States remains the best situated to play such a role if it gets its house in better order. Whoever is in the Oval Office in January 2021 has an immense opportunity to turn the page, and to ensure that the United States does well for itself even while it does immense good worldwide.
