May 5, 2017
Dear friends and colleagues,
The predictability predicament in the administration of President Donald J. Trump persists, leaving foreign governments and the American people bewildered and unable to forecast trends or comprehend relations with Washington, DC. Much of the unpredictability appears to stem from the president’s difficult relationship with members of his own Republican Party on Capitol Hill, while other issues may represent a learning curve inside the White House. Trump has expressed consternation about the challenges of governing: he rolled back positions staked on the campaign trail, called for a “government shutdown,” lamented the loss of his pre-presidential lifestyle, and noted that governance is considerably more difficult than he had imagined it to be.
There are many interesting developments in the Trump administration’s policy so far that are likely to affect global health, development, and humanitarian programs.
Secretary of State Rex Tillerson, speaking to State Department staff, clarified the relationship between Trump’s America First rhetoric and general foreign policy, saying a reform process was underway aimed at bringing “more balance” to the United States’ relations with its allies and enemies, tilting balances toward U.S. interests. But in some cases, White House themes and actual foreign policies will be “divorced,” he explained: “Policies can change, they do change, they should change. And it’s important for all of us to understand the difference between policies and values.”
Despite early signals that global health would be a decidedly low priority under his leadership, Secretary of Health and Human Services Tom Price will attend the May 22–28 World Health Assembly in Geneva, with a small official U.S. delegation. Sources tell me that Price is keeping his preferences for the next leader of the World Health Organization (WHO) close to his chest and that the delegation will include some individuals with diplomatic experience.
While the White House’s “skinny budget” [PDF] called for massive cuts in federal spending for biomedical research, public health programs, and the U.S. Agency for International Development, Congress passed an omnibus budget (covering spending until October 1, 2017, and forestalling a government shutdown) that actually increases support for the National Institutes of Health (NIH) by $2 billion and contains none of the foreign assistance cuts indicated by Trump. This congressional vote followed the March for Science, which saw millions of scientists and their supporters in cities all over the world protesting cuts and calling for evidence-based policymaking. I personally marched in New York because I felt the issues at stake were nonpartisan, akin, perhaps, to insisting that the world is round and rotates around the sun.
The New York Times recently delineated twenty-three environmental and climate-related policies that the Trump administration has already reversed, softened, or placed in a sort of regulatory limbo.
Promised devastation of climate and environmental budgets across multiple agencies did not materialize in the House omnibus bill, where even the vilified Environmental Protection Agency saw only a trivial cut, and the Department of Energy’s advanced energy research program that covers non–fossil fuel efforts was actually increased by a modest $15 million. Famine relief soared by nearly $1 billion.
Even the threatened 18 percent cut of the National Institutes of Health budget was reversed, adding $2 billion to the federal research institute’s budget. Still, as Wired magazine explained, “The omnibus bill spends 0.81 percent of U.S. gross domestic product on R&D [research and development] including what the country pours into defense.”
Though Trump has repeatedly denounced the soaring costs of pharmaceuticals and vowed to fight for lower-priced medicines, Congress has acceded to every demand from the drug industry lobbies, which spent an estimated $246 million on the 2016 elections, alongside the $95 million from the hospital lobby, $84 million from medical professional organizations, and $78 million from medical service companies. Far from lowering drug costs, Congress is promoting initiatives at the NIH favoring precision medicine, which is genetically tailored to the individual needs of those able to pay at a very high cost.
Trump’s campaign promise to repeal the Affordable Care Act (ACA), also known as Obamacare, within his first one hundred days in office met with political realism amid widespread protests against repealing without replacing. Congress’ replacement for the ACA, the American Health Care Act (AHCA), failed to muster sufficient votes in the House to pass on March 24. Under pressure from the White House, the House recrafted the AHCA, creating a potential law that places far more of the burden of health-care costs on patients’ shoulders. House Republicans put AHCA 2.0 up again for a vote on May 4. It passed the House by a squeaker, 217-213 vote, garnering a hailstorm of criticism from commentators of all political stripes as nearly everyone seems to have something detestable in the bill. Some members voted for the bill only to discover they should have read the act first—Congressman Chris Collins (R-NY), grilled by CNN, conceded he had not read the bill and was unaware it will cost his state’s Essential Health Plan $3 billion. Across the board, it seems the editorial boards of the nation’s newspapers have condemned the bill, finding a host of flaws that Collins and his colleagues failed to note before voting it through.
It is very unlikely to pass in the Senate. Not only is the Republican majority far slimmer in the Senate compared to the House, but GOP senators are concerned about holding onto their control after the 2018 midterm elections. As the Washington Post put it, “With one hasty and excruciatingly narrow vote, House Republicans have all but guaranteed that health care will be one of the most pivotal issues shaping the next two election cycles—including congressional, gubernatorial and state legislative races in the 2018 midterms and President Trump’s likely reelection bid in 2020.”
No matter what action the House takes on the AHCA and the fiscal year (FY) 2018 federal budget, the Senate will likely take a different stance. My foreign readers are reminded that the Republican majority in the Senate is slimmer, and several of the party’s most prominent senators, such as former presidential candidates John McCain (R-AZ), Lyndsey Graham (R-SC), and Marco Rubio (R-FL) have expressed views on foreign policy, health care, and global assistance that differ markedly from those of both President Trump and the House leadership.
Still, the real battle has simply shifted from the House to the Senate and from May to September. That is when Congress and the White House will wrangle over the FY 2018 budget, and Trump’s “skinny budget” will guide its broad outlines. Overall, the budget will shrink, the military’s share will increase enormously, and foreign aid, diplomacy, and all non-entitlement programs will shrivel down to their vines—in some cases, the vines will be uprooted leaving nothing but barren soil. A careful look at a leaked foreign assistance portion of the FY 2018 budget proposal [PDF] shows many columns displaying “-100%,” meaning the budget allocation is completely eliminated. The final two pages of that leaked section display “-100%” alongside nearly every global health program.
This will pose a major challenge for the upcoming Group of Twenty (G20) summit and World Health Assembly, both convening this month. Germany is pushing the G20 to review its members’ capacities to carry more of the donor load for global health and development programs, in light of expected drastic reductions in U.S. foreign assistance. At the World Health Assembly, the election of a new leader is likely to reflect concerns about confronting a post-globalization United States and United Kingdom.
One of the three candidates, Dr. Sania Nishtar, has pledged to “make no deals” in seeking votes and to commit to a single term in office. She writes, “The situation of the WHO is grave. The time for niceties is over. We are one disease outbreak away from an unimaginable catastrophe that could be worse than the Spanish flu outbreak of 1918. This means I am even willing to commit to one term in office, if that is what is required to accelerate reform within the WHO and eliminate the influence of detrimental political practices.”
Another candidate, Dr. David Nabarro, argues that he has “worked on global health issues in more than 50 countries for over 40 years. I know I am the best qualified person to be the director-general of the WHO and ensure that it is a WHO that is fit for the future.” That will be accomplished, Nabarro says, by policies that “will prioritize the building of capacity within countries” to respond to the health needs of their populations.
And the third office-seeker, Dr. Tedros Adhanom Ghebreyesus, is no doubt watching the AHCA fight in the United States with considerable interest, as his top priority is provision of universal health care through insurance to the entire world.
I will be attending the World Health Assembly and plan to Tweet a steady stream of updates. Follow me @Laurie_Garrett.
MOST RECENT WORK
With Ramanan Laxminarayan, director and senior fellow at the Center for Disease Dynamics, Economics, and Policy, I penned an expert brief for CFR.org, titled “Antibiotic-Resistant ‘Superbugs’ Are Here.” We especially underscore the threats posed by new drug resistance plasmids and rising animal use of antibiotics.
For Foreign Policy I wrote “I Will March for Science on Saturday — So Should You,” underscoring the dire career and financial straits of scientists under forty years old and the peril that we will lose our best young scientists.
I attended the Skoll World Forum in Oxford and partook in a panel, moderated by Dr. Larry Brilliant, “Ending Pandemics in Our Lifetime.” Brilliant was an especially lively moderator, the rest of the panel was wonderful, and it is good YouTube viewing.
Vulcan Productions released Unseen Enemy, a nearly two-hour documentary about Ebola and outbreak threats that has aired multiple times on CNN and dozens of other networks worldwide. Directed by Janet Tobias, the documentary will air worldwide for several months. I am a “character” in the film.
I delivered the keynote speech at Northeastern University’s pandemic-focused Annual Health Law Conference in Boston. My remarks looked at the links between pandemic threats, climate change, and other anthropogenic inputs.
Former National Security Council members Richard A. Clarke and R. P. Eddy will, in a few days, release a new book, Warnings: Finding Cassandras to Stop Catastrophes, published by HarperCollins. I am profiled in one of the book’s chapters, and we recently filmed a video in which the three of us discuss the dangers of emerging diseases and failures to recognize the HIV threat in a timely, humane manner—stay tuned.
In a few days, Gabriella Meltzer will be leaving the Council on Foreign Relations to start graduate studies in public health at New York University. Her final day at CFR is May 15. Please join us in congratulating Gabriella (email@example.com). Until I find a replacement, please feel free to reach out to me if you have any questions or concerns (firstname.lastname@example.org).
As always, I am interested in your feedback and I will endeavor to keep you informed on all top issues in global health.
Senior Fellow for Global Health
Council on Foreign Relations