Earlier this year, Joe Biden won praise in mainstream policy circles in the United States for making the case for “why America must lead again”. In the wake of his victory in the presidential election, some health experts hoped this would include making the US “a global health leader again”.
You can understand why these experts yearn for a different approach from the White House. Donald Trump’s four-year rule occasioned a destructive disengagement from the global health system, most evident in his withdrawal of the US from the World Health Organization (WHO) amid an unprecedented pandemic. In contrast, Biden has already promised to rejoin the organisation, with his newly released COVID-19 plan hailed by insiders as “a big reset”.
While reversing President Trump’s global health policies would benefit global health, we should also challenge Biden’s back to the future approach.
Today’s global health architecture has its roots in the International Sanitary Conferences, organised in the 19th Century to protect Europeans from diseases brought home by armies returning from brutal colonising campaigns abroad. In the modern era, global health governance has evolved into an arena for advanced economies to manage public health in the Global South. It is no surprise then that the US has been the dominant player.
The transition of power that we should care about is not just one from Trump to Biden, but from the US to the rest of the world.
Well before Trump, the global health system was failing. It entrenched inequalities in access to healthcare and, all too frequently, placed the lives of people across the world at the mercy of American domestic politics and trade policy.
Take the WHO for instance, the leading global organisation mandated with coordinating public health across the world. The WHO is kept on a tight financial and policy leash. It receives less than one-fifth of its funding from mandatory contributions. The rest is funded through voluntary contributions, before the Trump presidency, the majority coming from the US government. Voluntary funders influence WHO priorities, sometimes in conflict with the priorities negotiated by its appointed decision-making body, the World Health Assembly.
The consequence is that global health policy ends up reflecting US domestic policy: curtailed access to medicines, contraception, and abortion treatments, and blocked access to generic treatments to protect the profits of pharmaceutical companies, instead of the health of millions. A particularly egregious example of this undue influence is the so-called “global gag rule”. The policy has been enforced by every Republican administration since Reagan, prohibiting US-funded organisations from providing women with legal abortion services, leading to an increase in unsafe abortions.
Sure, Biden might suspend this policy for the years he is in office, but the underlying system would remain intact under his plan. The pro-corporate global health agenda would continue to drive organisations such as the World Trade Organization (WTO) and World Intellectual Property Organization (WIPO) to create an unequal playing field in health and trade agreements, prioritising the interests of American companies over public health. In the most recent iteration, the WTO member states voted to reject the application for a waiver on intellectual property rights for the coronavirus vaccine advanced by India and South Africa to allow local manufacture of vaccines for faster and cheaper provision to citizens.
Beyond this undesirable past, consider Biden’s COVID-19 response plan’s anti-Chinese flavour: To “expand the defenses … to predict, prevent, and mitigate pandemic threats, including those coming from China”. Not content with continuing Trump’s new cold war rhetoric, Biden’s transition team seems to be embedding it into an aggressive approach to “global health security”.
Some might dismiss such statements as mere political posturing, yet the recent past demonstrates the destructive power of the US presidential whim. One result of the US administration withdrawing from the Iran nuclear deal in 2018 and imposing increased sanctions was to reduce Iran’s ability to access essential medicines. When the pandemic hit, this lack of medicines and treatments increased the country’s death toll, which had already reached a shocking 42,000 by the end of March.
A return to the past, perhaps with a more aggressive anti-China twist, would damage global health. However, there are alternatives. Even as the US failed to provide global leadership during the COVID-19 pandemic, individual countries built innovative and effective ways to manage local responses. With a population of 95 million, Vietnam, which shares a long border with China, has suffered only 35 deaths from COVID-19. In fact, countries ostracised internationally at the behest of the US played a crucial role in supporting the global pandemic response. Cuba, for example, sent doctors to countries across the world to support strained health workforces.
The burden of death, ill-health, and destitution brought on by the pandemic has fallen on the historically marginalised peoples of the world. This unfair impact has its roots in racial and colonial hierarchies that have yet to be eradicated from their origins found in the days of the first international sanitary conferences. The enduring impact of this history makes recent calls to “decolonise global health” particularly critical.
As it returns to the global health stage, the US could play a vital role, but only if it radically changes course, not only from the Trump era but the policies that came before it. That would mean putting collective health outcomes first, through allowing the pursuit of universal healthcare around the world, undoing sanctions and corporate welfare regimes that restrict access to essential medicines, and sharing vaccine technology to end this pandemic.
The WHO and other global health organisations need to claim their autonomy so they can truly act in the interests of global health. That means pressuring donor governments to commit to unrestricted funding and compelling pharmaceutical companies to transfer technology to qualified vaccine manufacturers around the world. Countries in the Global South can aid this process by investing in their own innovation and health systems as well as advocating loudly for a more equitable global health system.
As Trump leaves the White House, merely resetting to what came before him is not the answer. Global health was in desperate need of reform four years ago, as much as it does now. Rather than returning to business as usual, we must democratise global health, based on solidarity, and respond in an equitable and just manner, to the challenges of COVID-19. Global health governance does need new leadership, and progressive activists around the world are already showing us the way.