There should also be a chapter on how members of Congress — including Republicans — avoided doing the insanely stupid and destructive things in Trump budget proposals, particularly when it comes to public health. The president’s 2018 budget plan (titled “A New Foundation for American Greatness”) would have cut funding for the National Institutes of Health by 18 percent and reduced funding for the Centers for Disease Control and Prevention to its lowest level in 20 years. This would have decimated medical and scientific research and public health programs on the eve of the covid-19 pandemic. Congress wisely ignored this invitation to “greatness.”
And a similar story can be told on a global scale. Year after year, Trump has recommended dramatic reductions, including a proposed 21 percent cut to foreign assistance in the 2021 budget. Year after year, Congress has ignored this cruel and short-sighted assault on the United States’ global role, generally holding budgets roughly flat.
Here, as elsewhere, things could have been worse. Global health programs such as the President’s Emergency Plan for AIDS Relief (PEPFAR) — created during the George W. Bush administration, and augmented in the Barack Obama era — have survived the Trump era. As World AIDS Day 2020 comes around, that is worth celebrating.
But now all this difficult work — all this brilliantly improvised effort — is threatened by the covid-19 pandemic that is swamping fragile, developing-world health systems. Nearly 20 percent of countries are experiencing covid-related disruptions in AIDS testing and treatment. The economic consequences of the pandemic could push an additional 40 million Africans into extreme poverty, making them harder for health efforts to reach. And the eventual provision of vaccines in the developing world is going to be a complex and ambitious effort in itself.
But we have a few things going for us. The global AIDS response has provided the example of a complex and ambitious health program in the developing world succeeding beyond expectation. Twenty years ago, almost no sub-Saharan Africans had access to AIDS treatment. Today, that figure is more than 18 million. And the health infrastructure built around this effort can be helpful in vaccine distribution — just as PEPFAR’s infrastructure was helpful in defeating Ebola. We are not starting from scratch.
There is one other important advantage in this effort — an incoming administration that believes in internationalism and global engagement. But it will need to quickly provide leadership on a broad agenda:
1) Make sure that developing countries are not last in line for the vaccines. This should involve joining the COVAX facility, which will allow poor and middle-income countries to purchase a broad portfolio of vaccines. Already, a few wealthy nations have bought more than half of the expected supply of the leading vaccine candidates.
2) Pass a supplemental spending bill that provides emergency funding to reinforce developing world health systems and to increase their ability to prevent, detect and track outbreaks.
3) Continue our moral and financial commitment to the success of programs such as PEPFAR, Gavi, and the Global Fund to Fight AIDS, Tuberculosis and Malaria. We are already losing years of previous progress against other infectious diseases. That can’t be allowed to become decades.
4) Give a needed and overdue boost to our international affairs budget. This is a moment — when large challenges require an expansive U.S. role — to invest in nonmilitary tools of foreign policy.
It has been a major achievement, even a bit of a miracle, that the bipartisan global health accomplishments of two decades were preserved against a president claiming to serve “America First.” This is a tribute to committed members of Congress — such as the inimitable, incomprehensible Sen. Lindsey O. Graham (R-S.C.) — and their staffs. It is a tribute to a model bipartisan coalition comprising religious groups, business organizations, military leaders and nongovernmental organizations that advocate for U.S. global engagement. And it is a tribute to the activism of groups such as ONE (where I spend some of my time) and the U.S. Global Leadership Coalition (where I’m on the board).
But, now, their work is threatened by covid-19, at a time when a strong international health infrastructure is needed to fight the pandemic. The gains of the past make possible the gains of the future. A new administration will need to tend to both.