One of the noblest things the United States and other developed nations have done over the past few decades has been to save the lives of tens of millions of people in poorer countries from preventable infectious diseases. And one of the bank-shot cruelties of the coronavirus pandemic has been to seriously undermine those gains.
Take the case of the Global Fund to Fight AIDS, Malaria and Tuberculosis. The United States has its own highly effective programs to oppose infectious diseases, including the President’s Emergency Plan for AIDS Relief (PEPFAR) and the President’s Malaria Initiative (PMI). But the Global Fund was created in 2002 to share the burden of such efforts. The United States’ portion of the fund’s budget is capped at 33 percent — meaning that other donors must come up with 67 percent to trigger America’s full contribution.
During the two decades of its existence, the Global Fund has distributed $55 billion and saved, along with its local partners, an estimated 44 million lives. The combined death rate from the three diseases has been reduced by more than half in the countries where the fund is active.
In the process, the Global Fund has carved out an essential role in improving the health systems of developing countries — building new labs, improving supply chains, training community health workers. Over the years, improvements in global health came so broadly and rapidly that, in 2015, the United Nations set as Sustainable Development Goal 3 the ending of AIDS, malaria and tuberculosis as public health threats by 2030.
Then came 2020 and the arrival, rapid spread and genetic mutations of a new respiratory infection. This (naturally) redirected global attention and complicated local efforts to prevent and treat existing diseases. Reversals came quickly. For the first time since the Global Fund was founded, progress against all three diseases has deteriorated.
Another of the world’s deadly respiratory diseases, tuberculosis, felt the worst of the global health system shock. The number of people treated for TB in countries where the Global Fund invests fell by more than 1 million. Malaria cases and deaths increased. HIV testing declined by over 20 percent.
To fix this derailment, the Global Fund estimates it will require $18 billion over the next three years — nearly a 30 percent increase from the funds it raised in its last replenishment, three years ago. This means that donor nations need to increase their pledges by 30 percent during a time when war and rising energy prices complicate the politics of generosity.
It is a difficult but clarifying time for global health. Twenty years ago, the United States and other developed nations made the humane decision that preventable disease should be prevented. And over the years, startling success made the eradication of some of humanity’s worst microbial enemies seem possible. It was what the Greeks called a “kairos” moment — one of great opportunity and awesome consequence.
Now, wealthier countries face another such moment. Do they resume one of history’s great moral ambitions, or do they signal that preventable diseases should be prevented — except for the most vulnerable people on the planet?
One source close to the negotiations says the results so far are “mixed.” The Biden administration has acted admirably. It has proposed about a 30 percent increase in its funding pledge, to $6 billion (if other nations step up), and will host the Global Fund’s replenishment summit in New York this month. The German government, under tremendous economic strain from energy disruptions, has signaled an increase of 30 percent. Japan has significantly raised its pledge as well.
The wild cards are Britain and France. Britain’s decision will indicate the attitude of a new prime minister and a new government toward foreign assistance. People close to the negotiations fear that flat funding might be the best outcome. They also hear disturbing rumblings that President Emmanuel Macron’s French government — which hosted the last replenishment summit and is the Global Fund’s second-largest contributor — might increase its pledge by only 5 to 15 percent, which would be a serious disappointment.
Leaders of donor countries all face the same question: Is there a zero-sum game between serving my people and helping the world’s poorest? As a matter of substance, the past few years have answered that question. To fight any future pandemic, the world depends on the ability of health systems in developing countries to detect, contain, monitor, treat and vaccinate against new threats. There is a close relationship between the ability to fight present infectious diseases and the ability to fight newly emerged infectious diseases. Building such capacity is one of the Global Fund’s strengths.
What remains is a political matter: Does a leader try to gain domestic benefit from inflicting needless pain on poor and vulnerable people? The question is not, however, just political. It is ultimately a moral test.