Trump Administration Puts the U.S. at a Crossroad for Global Health Aid
Perhaps the most optimistic outlook was voiced, half-jokingly, at a recent medical conference by Dr. Michele Barry, head of Stanford University’s Center for Innovation in Global Health.
“Well, he’s a germophobe,” she said of Mr. Trump. “So that’s got to be good for the C.D.C.”
Americans blow hot and cold on global health. Many go for years without thinking about the fate of rural Africans or Latin Americans — and then convulse with fear when an outbreak of Ebola, Zika or swine flu emerges, upset that there was so little warning and no vaccine.
Americans also have an extraordinarily inaccurate view of how much is spent on global health. When pollsters ask Americans to estimate what percentage of their tax dollar goes to foreign aid, the answers average 25 percent — and most say it’s too much.
In truth, foreign aid is just 1 percent of the federal budget, and health — as opposed to military or development aid — is only about a quarter of that. It totals about $9 billion a year out of a $4 trillion budget.
When poll respondents are told it is that small, their feelings shift sharply. Only 26 percent say it’s too much; 27 percent believe it’s too little. The latter say they favor spending more chiefly for two reasons: to protect America from epidemics and to improve the nation’s image abroad.
“We need to get better at telling that story — what a relatively small amount of the budget is spent to produce such big returns for the U.S.,” said Chris Collins, president of Friends of the Global Fight, an advocacy group for the Global Fund to Fight AIDS, Tuberculosis and Malaria.
On the campaign trail, Mr. Trump was rarely asked for his thoughts on global health. On foreign aid in general, he usually voiced an “America first” agenda, saying tax dollars should go to rebuilding this country.
“It is necessary that we invest in our infrastructure and stop sending foreign aid to countries that hate us,” Mr. Trump said when announcing his candidacy in 2015.
But a few months later, he was asked by a college student at a New Hampshire forum whether he would commit to doubling the number of people on AIDS treatment around the world.
“The answer is yes,” Mr. Trump said. “I believe so strongly in that, and we are going to lead the way.”
By contrast, Vice President-elect Mike Pence has a long record of voting for global health spending.
In 2003, he voted for George W. Bush’s Pepfar, which provided $15 billion to fight AIDS and tuberculosis in Africa. It united foreign-aid-favoring liberals and evangelical conservatives with ties to missionary hospitals. In 2008, Mr. Pence backed legislation that authorized $50 billion more for Pepfar and for the President’s Malaria Initiative.
“The Bible tells us to whom much is given, much is expected,” Mr. Pence said then. “I believe the United States has a moral obligation to lead the world in confronting the pandemic of H.I.V.-AIDS.”
Yet Mr. Pence’s conservatism worries some health advocates.
“Trump has no record, Pence does,” said Serra Sippel, president of the Center for Health and Gender Equity, which advocates expanding women’s rights, including abortion. “I’d say it’s not only hostile to women, but hostile to science.”
Support for global health spending is bipartisan but it varies by disease. Some ills are more controversial than others.
Saving mothers and babies is always popular, so the United States is a major supporter of GAVI, the vaccine alliance, which provides shots against tetanus, measles and many other diseases.
Stopping malaria is also widely supported. Funding for the President’s Malaria Initiative has risen to $619 million today from $30 million in 2006, in part because it has been so remarkably effective. Worldwide, malaria deaths have dropped 60 percent.
The malaria initiative has been quietly run for 10 years by the same man President Bush first appointed to run it: R. Timothy Ziemer, a retired Navy admiral who is also an evangelical Christian. (He was born in Vietnam to medical missionaries.)
The effort also has the Pentagon’s support, because the Army and Navy have researched mosquito-borne illnesses since the Spanish-American War. The campaign also gets billions of dollars from Bill and Melinda Gates, who in 2007 made malaria elimination one of their goals.
(Mr. Gates met Mr. Trump in Manhattan last week, but a foundation spokeswoman declined to say what they discussed, other than “innovation,” which she said could include medical innovations like an AIDS vaccine, for example.)
Also uncontroversial are efforts to turn back pneumonia, diarrhea and the “neglected diseases,” many of which are caused by worms. But little foreign aid money is devoted to them, even though the first two kill many newborns and worm diseases make toddlers anemic and stunted.
Containing polio is somewhat controversial because it’s so expensive. There are now only about 100 cases in the world each year, but the effort to eradicate it consumes $1 billion a year.
Much of that comes from private donors, including Rotary International and the Gates Foundation. Had the eradication drive never happened, it is estimated that polio would have crippled 16 million children by now.
Treatment of tuberculosis is politically touchier, because it often arrives in the United States with immigrants, whom Mr. Trump is famously hostile to.
Aware of that, some groups are shading their messages. For example, the C.D.C. built an exhibit about refugee health for a recent tropical medicine conference. Its overall tone was sympathetic; it included a heart-rending video of Syrian families screaming for help as their boats sank.
But the exhibit also featured a walk-through diagnostic clinic that emphasized how the C.D.C. keeps America safe by helping United Nations agencies screen refugees for tuberculosis.
The most controversial disease is the one that gets the most money and attention: AIDS. Four global AIDS coordinators have come and gone in the last decades, liberal and conservative advocates for AIDS are constantly at one another’s throats, and spending on AIDS was essentially flat during the Obama administration.
Some advocates, like Ms. Sippel, come from the gay-rights and abortion-rights movements. They fear that Mr. Pence will reinstate Bush-era restrictions, some of which had recently been relaxed or overlooked.
They include bans on funding health clinics abroad that perform abortions, the requirement that funds be earmarked for teaching abstinence, and a requirement that all fund recipients pledge to oppose legalizing prostitution.
Advocates on the left argue that those provisions backfire: Abstinence lessons do not reduce H.I.V. infection rates, prenatal clinics overseas that offer abortions also serve H.I.V.-positive women who need help to avoid infecting their babies, and some of the most effective anti-AIDS organizations overseas are run by and for prostitutes.
Yet Mr. Pence has been known to change his mind based on scientific evidence. As Indiana governor, he strongly opposed clean needle swaps, even though they have been shown to reduce H.I.V. infections among drug users.
When needle sharing among addicts triggered a sudden AIDS outbreak in Indiana last year, however, Mr. Pence allowed needle swaps in the most-affected counties.
Funding decisions for H.I.V. prevention have long been mired in an ideological battle pitting condoms versus abstinence. But experts note that the conflict is fading: Neither condoms nor abstinence has stopped the AIDS epidemic among gay Americans or heterosexual Africans.
Now more emphasis is being placed on getting all the infected on treatment, which reduces infectiousness, and getting all the vulnerable on prophylactic drugs. In Africa, circumcision is also emphasized.
Some advocates hope that the large circle of military men consulted by Mr. Trump will push him to spend more on health. Besides its historical interest in tropical diseases, the military maintains laboratories in Egypt, Indonesia, Peru and elsewhere that often act as an early warning system for epidemics.
“Department of Defense and national security people know that no wall will keep disease out,” said Amanda Glassman, director for global health security at the Center for Global Development, a Washington think tank. “They care about biosecurity, and about monitoring outbreaks and antibiotic resistance and things like that.”
Experts also note that regions where the United States spends the most on health — Africa and Southeast Asia — produce few Islamic State recruits or suicide bombers, and that “sending foreign aid to countries that hate us,” as Mr. Trump once put it, actually worked pretty well in Germany and Japan after World War II.
America’s image still shines in some parts of the world because of what the country has done for the poor. In Uganda, recipients of AIDS drugs sing a chorus: “Thank you America, for saving my life.”
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