US elections and a foreign policy for pandemics

The COVID-19 pandemic has now had significant effects throughout the wold, shutting down economies and leading to the deaths of hundreds of thousands of people. Beginning in China in the midst of a US election year, it has proven politically charged. The USA has been especially hard hit by COVID-19, with more than 6 million cases as of Sept 1, 2020, more than any other country. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has laid bare the limitations of US foreign policy in preventing and stopping pandemics, not only during the current Trump administration but also over the past decade. Isolationism has not enabled the USA to stop the spread of SARS-CoV-2. But global health programmes centred on sharing US expertise with low-income and middle-income countries (LMICs) have also not ensured the USA, or the world, can respond effectively in the face of a complex virus and global competition for the goods and technologies to stop it. The next US administration should shift foreign policy towards thinking and acting holistically about pandemics, strengthening multilateralism, and embracing solidarity. Learning lessons from what has worked, and what has not, the next US administration should launch a concrete, sufficiently funded global pandemics initiative with three focuses. First, to better link responses to HIV, tuberculosis, and malaria with those addressing emerging outbreaks. Second, to put climate change at the centre of global health and health into international climate policy. Third, to build multilateral capacity and power. In tackling pandemics as a central element of engaged foreign policy, the next US administration could lead an historic shift.

The separation between pandemics of today and those of tomorrow is no longer tenable. Yet, the danger remains that efforts flowing from COVID-19 will focus on keeping future diseases away from high-income countries without addressing the major killers of people in LMICs. In recent years, a bifurcation has arisen between US global health programmes aimed at addressing contemporary health issues of LMICs (including the President's Emergency Plan for AIDS Relief, the President's Malaria Initiative, US contributions to the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and others) and those aimed at preparedness and response to new threats, centralised in the Global Health Security Agenda. This separation leads to problems. US global AIDS programmes have been highly successful in public health (saving many lives),¹ as an exercise of soft-power diplomacy (improving US approval ratings),² and in advancing broader goals of strengthening governance.³ Yet, too often framed as one-way sharing of aid and expertise to contexts with a high HIV burden, insufficient efforts have been made to learn from public health leaders in Africa about what has worked and to adapt it to the US context. This missed opportunity has been visible during COVID-19, as African Centres for Disease Control and Prevention (CDCs) and public health agencies in countries with a high HIV burden have been more nimble and effective than have many of those in the USA.⁴

On the other hand, efforts to stop outbreaks of new and dangerous pathogens framed as global health security have been directly linked to the health of people in the USA. Yet, the security frame can, at times, lead to racialised models of global health that neglect the health needs of people in LMICs (eg, tuberculosis) if a security threat to the USA is not present.⁵ Oversecuritisation can also encourage putting military staff in charge when public health officials are needed and trigger mistrust of public health efforts.⁶

A new initiative could drive a more holistic approach, particularly since recent pandemics (from Ebola to severe acute respiratory syndrome to COVID-19) have shown the importance of a similar set of inputs across diseases and geography such as boosting laboratory capacity, increasing the health workforce, and sharing access to countermeasures or treatment. The USA has as much to learn as it does to teach; leaving global health only to aid agencies makes little sense. Housing a new initiative at the US State Department could ensure the political capacity needed to succeed in this area,⁷ with support from the US National Security Council, while integrating work by the US CDC, USAID, the US Defense Department, and other agencies.

Climate change policy too remains dangerously disconnected from pandemic efforts. Shifting range and seasonality of mosquitos could put more than a billion people at new risk of disease,⁸ while flooding and destructive storms are already driving outbreaks of infectious diseases like cholera. US foreign policy on climate must go beyond the Paris Accords to include robust global health mitigation and adaptation efforts, which was largely missed even during the Obama administration.⁹

The final pillar of a new solidarity-focused pandemics initiative must be multilateralism. The Trump administration has scapegoated WHO by withholding funds, refusing to participate in global coordination on a vaccine for COVID-19, and moving towards official withdrawal from WHO.¹⁰ Yet, simply blocking US withdrawal from WHO will be insufficient. COVID-19 has shown us that pandemics require more powerful global health governance on at least two fronts. First, WHO and other agencies need more power behind declarations of emergency; International Health Regulations need to be expanded to address such issues as coordinating equitable access to diagnostic, treatment, and vaccine goods. Second, more inclusive and impactful aid is needed. The Global Fund to Fight AIDS, Tuberculosis, and Malaria, in particular, has proven transparent, effective, and able to engage affected communities in ways many bilateral programmes and institutions (such as the World Bank) have not.³ A new pandemics initiative should focus on supporting inclusive institutions.

US foreign policy on COVID-19 has failed. COVID-19 has shown the need to reframe global health in terms of solidarity, putting resources behind collective mobilisation of expertise from high-income countries and LMICs and building capacity to save lives worldwide. In 2019, the USA spent about US$8·9 billion, or 0·19% of the US federal budget, on pandemic-related global health programmes.⁹ That amount is clearly insufficient. Doubling pandemics spending, channelling it through high-impact multilateral and bilateral channels, and building a political strategy to increase the power of global health governance could be a game changer. The key first step, however, will be embracing a foreign policy rooted in solidarity and the shared self-interest laid bare under COVID-19.