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US global health leadership hangs on election result

Friday, 21st of October 2016

US global health leadership hangs on election result

The Lancet, Volume 388, No. 10055, p1969–1970, 22 October 2016

Susan Jaffe

DOI: http://dx.doi.org/10.1016/S0140-6736(16)31898-0

Published: 22 October 2016

© 2016 Elsevier Ltd. All rights reserved.

On most issues, the US presidential candidates have polar opposite views; engagement in global health is no different. Susan Jaffe, The Lancet ´s Washington correspondent, reports.

Americans will choose their next president in less than 3 weeks and yet some global health experts still wonder what would happen to the international health programmes that the USA has championed in recent decades if the Republican contender, Donald Trump, is elected. The uncertainty comes despite the Ebola virus and Zika virus threats that made global health into front-page news.

Trump ´s opponent, Democrat Hillary Clinton, has 30 years of political experience that includes representing New York State in the Senate, and serving as President Barack Obama ´s Secretary of State. She has a record of support for health programmes for women and children, said Jennifer Kates, vice president and director of global health and HIV policy at the Kaiser Family Foundation. Clinton supports continued US leadership in global health to respond to the global HIV epidemic and wants to establish a public health preparedness and response fund, said Kates. Clinton visited Puerto Rico while residents were coping with Zika virus. Her website offers policy papers on health and more than three dozen other campaign issues.

By comparison, Kates notes that Trump, a billionaire real estate developer, has never served in public office and has expressed few opinions or policy statements about global health. And what he has said has been puzzling. At a public meeting a year ago in New Hampshire, Trump was asked if he would support the President ´s Emergency Plan for AIDS Relief (PEPFAR) and double the number of people getting AIDS treatment to 30 million by 2020.

“Well, I like committing to all of those things”, he replied. “Those are great things. Alzheimer ´s, AIDS, so many different—you know, we are close on some of them. On some of them, honestly, with all of the work that has been done—which hasn ´t been enough, we are not very close. But the answer is yes, I believe so strongly in that. And we ´re going to lead the way. We ´re going to lead the way on that.”

But when a group of scientific organisations surveyed the two candidates about global threats from climate change and pandemic diseases last month, Trump was less enthusiastic: “Our best input to helping with global issues is to make sure that the United States is on the proper trajectory economically”, he said. “We cannot take our place as world leader if we are not healthy enough to take care of ourselves. This means we must make sure that we achieve our goals in tax reform, trade reform, immigration reform, and energy independence. A prosperous America is a much better partner in tackling global problems that affect this nation achieving its national objectives.”

Clinton ´s response stressed the importance of strengthening the Paris climate change agreement as well as addressing disease outbreaks. “It is within our national interest to think beyond our borders, and through our leadership, do everything we can to foster peace, health, and security around the world. In the United States, we need to break the cycle in which our own public health system is beholden to emergency appropriations for specific epidemics. We can do this by creating a dedicated rapid response fund to help shore up our defences, accelerate development of vaccines and new treatments, and respond more effectively to crises. We will also create a comprehensive global health strategy that moves beyond the disease-by-disease emergency model and seeks to build a robust, resilient global health system capable of quickly responding to and ending pandemics.”

The difference between the presidential candidates could not be starker for Laurie Garrett, a senior fellow at the Council for Foreign Relations. “I think we ´re all rather convinced Donald Trump has no knowledge of, interest in, nor commitment to anything that falls under what we currently consider global health”, she said. “There is no basis for judging what he would actually do as president with global health issues.”

The reverse is true of Hillary Clinton, Garrett continued. “She ´s got a massive agenda for global health and was very committed to it as Secretary of State, especially everything that linked health and women ´s issues: maternal health issues, reproductive health, and safe access to food and water for women.”

USA ´s role in global health

Through its National Institutes of Health (NIH), the USA is the world ´s largest funder of biomedical research, said Roger Glass, director of NIH ´s Fogarty International Center. Last month, Glass addressed the Committee on Global Health and the Future of the United States, a multiagency group convened by the National Academies of Sciences, Engineering, and Medicine to produce an expert consensus study to advise the next administration. “As we expand the frontiers of science, some of the most critical questions can only be addressed by working in the global health space”, he said. Advances in HIV drugs and prevention strategies such as circumcision, microbicides, and prevention of vertical transmission of HIV, were developed “in areas with a high prevalence of disease and where these interventions would be lifesaving”.

Oral rehydration therapy was first developed as “a home-based remedy” to prevent dehydration among cholera patients in Bangladesh, he said. Researchers developed a vaccine for hepatitis B in Taiwan and a family in Colombia that has inherited early-onset Alzheimer ´s disease is providing researchers a rare opportunity to investigate the biomarkers of the disease.

The US Centers for Disease Control and Prevention (CDC) is a global health agency, said CDC director Tom Frieden. It has a US$2·6 billion budget in global health for supporting the work of 2000 staff in 60 countries. “Even if you define our mission narrowly as protecting Americans, there is no way we can do that without engaging with the world”, he said. “Our mission is clear—to save as many lives as possible”, he said.

Frieden noted that the USA provides half of all HIV treatment globally through PEPFAR, which has been “a tremendous success”. Although there has been progress in reducing the number of malaria and polio cases around the world, Frieden said there is still more work to be done to strengthen public health systems in other countries. Measles still kills 100 000 children a year worldwide, he said.

At a meeting of the Global Health Security Agenda (a multilateral and multisectoral initiative to enhance global capacities to prevent, detect, and rapidly respond to infectious disease threats) in the Netherlands last week, Frieden met with the health minister of Mali, where he said, “they have a horrible problem with malaria. Despite doing a lot of things well, they ´ve got the highest malaria rates in the world.”

“We need to continue what ´s working in the President ´s Malaria Initiative but also develop the next generation of tools for malaria and use rigorous analysis to improve outcomes”, he said.

“For example, research we are doing suggests that bednets, which we had hoped would last 3 years, are not lasting 3 years in the field”, he said. “That means infants are dying and mothers may be having bad outcomes of pregnancy.”

Another area where it is “most important to continue to build momentum is the Global Health Security Agenda”, said Frieden. It was launched in 2014, when WHO reported that 70% of countries were unprepared for epidemic threats.

“We think of this as a real win-win”, Frieden said last week, a day after returning from the Global Health Security Agenda meeting. “It ´s a win for the US because if we can stop outbreaks overseas, we won ´t have to deal with them here. It ´s a win for other countries because they are building their own capacities.”

Challenges for the next president

The new president will take over at a time when financial support for global health has been relatively unchanged since 2010, hovering at about US$10 billion. Ensuring that the USA makes the necessary investments in global health is something the next president is going to have to deal with, said Rob Nabors, director of policy and government affairs for the USA, Canada, and Asia-Pacific at the Bill & Melinda Gates Foundation.

Kates said that in Kaiser Family Foundation polls, “the public has consistently said they support US involvement in global health and they think it is the right thing to do.”

“One of the reasons global health security has bipartisan support is because it is doing well by doing good”, said Frieden. “I think for whoever is in the White House, whoever is in Congress, money is [going to be] tight and [it ´s important] to show very clearly that the dollars we ´re spending are great investments, they save money and they save lives both here and around the world.”

In addition to selecting a president, voters will be deciding whether to replace about a third of the US Senate and all 435 members of the US House of Representatives. Republicans dominate the House but support for Trump could also sweep enough Republicans into the US Senate for them to become the majority party and take control.

“If Donald Trump is elected president of the United States and the Republicans retake the Senate, I think everything we call global health will be up for grabs”, said Garrett.

For The Lancet ´s US election 2016 hub see http://www.thelancet.com/USElection2016

For more on the US Government and global health see http://files.kff.org/attachment/fact-sheet-The-US-Government-and-Global-Health

For more on the Committee on Global Health and the Future of the United States see http://nationalacademies.org/hmd/Activities/Global/GlobalHealthFutureofUS.aspx