Council Special Report: A New U.S. Foreign Policy for Global Health

Tuesday, October 10, 2023
Lucas Jackson/Reuters

Senior Fellow for Global Health and Cybersecurity, Council on Foreign Relations; Author, A New U.S. Foreign Policy for Global Health, Council Special Report; @D_P_Fidler

Dean, DeLamar Professor of Public Health, and Professor of Epidemiology and Medicine, Columbia University Mailman School of Public Health; CFR Member (speaking virtually)

Dean, School of Public Health, Brown University; Former White House Covid-19 Response Coordinator and Assistant to the President, Executive Office of the President


Former Foreign Secretary, National Academy of Medicine; Former Commissioner, U.S. Food & Drug Administration; Member, Board of Directors, Council on Foreign Relations

Panelists discuss the future of U.S. foreign policy on global health and ways to address future pandemics, climate change, health-related development goals, and other challenges in a divided country and geopolitical world.

This meeting is made possible by the generous support of the Bill & Melinda Gates Foundation.

HAMBURG: Welcome! I’d like to begin this important session here at the Council on Foreign Relations. And welcome all of you who are here in the room with us, and also those of you who are joining virtually. I understand we have quite a number of members joining virtually. We also have one of our panelists joining virtually and it looks like the IT systems are working so far, so delighted about that. 

This session is focused on a new report coming out of the Council called A New U.S. Foreign Policy for Global Health. This is officially the launch of this new report. And we want to use this session to hear a little bit from its author, David Fidler, about what’s in the report, the sort of context for writing the report, and what the future may hold, in his thinking, as he did this important work. We also want to draw on the interests, experiences, and perspectives of our very distinguished panel, and also engage members in terms of the issues that they’d like to raise in the second half of this session. 

I think this is a particularly timely topic. Obviously, this is an issue, foreign policy and global health, that has been around and on the table for discussion and real-world action now for a very long period of time. But this may now be one of the most challenging times, as we think about what’s needed now and prospects for the future. Obviously, we’re coming out of a major global public health crisis, the COVID-19 pandemic and a lot of lessons to be learned. But we also recognize that we are in the midst of a very complex and changing world. Not an easy time for foreign policy, not an easy time for global health. And certainly, we are facing a set of concerns from the foreign policy perspective that are deeply troubling. 

Already the challenge of a war in Ukraine, now is this devastating new war in Israel in the Middle East. Obviously growing tensions with China, conflicts in many parts of the world. Growing inequities in important aspects of global health and beyond. Economic concerns domestically and globally, that underpin aspects of our foreign policy and our opportunities to advance global health and so much more. Transnational threats like infectious diseases and climate change are very much on all of our minds as we come into this discussion. Other threats in the health domain as well from demographic changes and, importantly, an aging population, the burden of chronic disease, and other concerns.  

As well as a context that is, you know, really, I think, very troubling of growing populism, nationalism, and political divisiveness, decreased trust in government and important institutions. Including a mistrust of science and public health, both the content and the leaders, fueled, of course, by misinformation and disinformation campaigns that seem to have continued to grow. So just a short list of the challenges before us, the things that David had to be thinking about as he worked on this report, and the things that will be shaping our U.S. foreign policy for global health going forward. And we hope to be able to add to our thinking and insights through the conversation this morning. 

I want to introduce our panel. 

Importantly, David Fidler, who I’ve already referred to, He’s the senior fellow for global health and cybersecurity here at the Council on Foreign Relations, as well as the author of this special report. But many other important publications on global health, global governance, and the law. And for a long time with a very distinguished professor at Indiana University working on this set of issues. 

We also have Ashish Jha, who’s dean of the School of Public Health at Brown University and, notably, also the former White House COVID-19 response coordinator and assistant to the president. Individual known to many of us from his work in public health, but known to the public because he is such an effective communicator and talking head.  

And we also are joined by Linda Fried, our talking head today on the screen. You’re on multiple screens, in fact, Linda, just so you know. She’s the dean and DeLamar professor of public health, and professor of epidemiology and medicine at Columbia University Mailman School of Public Health, a distinguished CFR member, and a thoughtful scholar and advocate for public health. 

So with that, I think I will remind everyone that this meeting is on the record. I guess I should have introduced myself. I’m Peggy Hamburg. I’m a member of the Board of Directors here at the Council on Foreign Relations. I’m a physician, scientist by training, but most of my career has been in public health and public service, including commissioner of the U.S. Food and Drug Administration, and commissioner of the New York City Department of Health, and someone who has had the opportunity to work on this set of issues over a long period of time and with many of you in the room and that are joining us virtually. 

So I think let’s turn now to hear very briefly from David about the contours of this report and, you know, how he has framed this critical set of issues. Then I’ll turn to Ashish for his perspective, both on David’s comments on the report, but also addressing issues that he thinks, you know, should be part of the discussion and on the table as we address this important issue. And then, Linda, I will turn to you to further elaborate on the critical issues that are before us with respect to foreign policy and global health. 

So over to you, David. 

FIDLER: Thank you, Peggy. And thank you everyone for coming, and those who are watching virtually. 

Just very brief background. This Council special report is really a capstone analysis of a two-year project on U.S. global health engagement generously sponsored by the Bill and Melinda Gates Foundation. It had a number of components. This was one of those and it, fortunately, now is completed. And there’s a sense of stepping back and looking over the course of the two years—with the articles in Think Global Health, with workshops, with other meetings and interactions—pulling together an analysis that really tries to look at four questions. I don’t use these questions specifically in the report, but I’m going to lay them out because I think it might be helpful for our conversation today. And I do hope the conversation goes well beyond what my—what you may want to ask or say about the report, because the report doesn’t cover the entire terrain of global health issues and how U.S. foreign policy should or should not respond to those. 

So in the report, I really attempt to ask four questions, and then I provide my answers. Where are we today? The first question. Where are we today, coming out of the COVID-19 pandemic, concerning our foreign policy approach to global health? Second, why do we find ourselves in this unsatisfactory situation? Third, what political lessons have we learned about U.S. global health policy, not just in the pandemic but going back, you know, at least twenty-plus years before that. And I emphasized political lessons rather than global health or public health lessons, on which there’s lots of analysis. And finally, fourth, how do we move forward? How do we make progress, given the situation that U.S. foreign policy now faces and the challenges in global health?  

All right, just very—I’m just going to give you a very quick overview of how I answered these questions. Not getting into a lot of detail but just providing the top-level overview. Where are we today? I think we face a real predicament. On the one hand, we have a lot of incentives to transform U.S. foreign policy on global health because, despite at least twenty years of being a leader in global health, we weren’t prepared for a pandemic. And for a long time, we knew this was the greatest acute health threat to U.S. national interest. Second, we’re not prepared for the health threats coming with climate change. And again, that’s the greatest chronic health threat to U.S. interests. And that’s been—again, experts have been warning about this for a very long time. 

On the other hand, transforming U.S. foreign policy on global health faces obstacles that are created by populism, nationalism, partisanship in our domestic politics, as well as the return of geopolitics at the international level. So we have an imperative to transform our foreign policy on global health, but I think, at least in my experience of working on this issue for twenty-five years, these are the worst domestic and international political conditions that I think we faced in a very long time. All right, how did we get here? OK, I do a historical analysis in the report that goes back to the Cold War, through the responses of the Trump and Biden administrations on COVID-19. 

Very briefly, after the Cold War, the U.S. made a change in how it looked at international global health issues. It began to see this topic area as important to all of its national interests—national security, national economic power and wellbeing, development, humanitarian assistance, the promotion of democracy, the maintenance of an international system favorable to U.S. interests and U.S. values. This was a real change, right? And that sea change and the global health leadership that followed was enabled by underlying political conditions—U.S. global primacy, spread of democracy, and bipartisan commitment to address some transnational threats, including infectious diseases. However, in the decade—the 2010s—the decade immediately before COVID-19, those enabling conditions broke down. Geopolitics returned, democracy was in decline, U.S. politics became polarized and bipartisan. And you can see the results of that breakdown in the responses of both the Trump and the Biden administrations, as well as U.S. responses, if you can call them that, to the threat of climate change. 

What political lessons have we learned then from that historical overview and the predicament that we face? I list a number of political lessons in the report. I won’t go into them now. I’ll just mention a couple here. I think one political lesson here is that U.S. foreign policy on global health failed to protect the range of national interests associated with global health involvement. And here, I think particularly failed with regards to our vital interests in national security and our national economic power and wellbeing. I also think a political lesson learned from this is that global health leadership did not help the United States protect the liberal democratic order. We can talk, you know, more about those things, but, again, particularly in relationship to the linkage of our global health engagement with democracy, with fostering and sustaining an international system favorable to U.S. interests and values, it’s hard to see that global—our global health leadership made much of a contribution to the interest that we had in protecting the liberal international order. 

All right. How do we move forward? I make sixteen recommendations in the report. I’m not going to go into any of them now. They’re grouped under what I think are the key sort of strategic targets that we have coming out of COVID and in relationship to climate change, or at least the policy failures that I sense we’ve had with pandemics and climate change. So they’re clustered under security, capability, and solidarity. So we need to take some actions here to refocus our U.S. foreign policy on global health to protecting those vital national interests that we have. To do that, you got to rebuild some of the capability, both international and domestic.  

Several of my recommendations deal with trying to improve the capability and the performance of public health in the United States, because if we don’t have some—you know, a care and attention to what’s going on the United States, that’s going to damage our ability to act globally. We saw that with COVID-19. And I think we’re starting to see that with climate change. And then finally, solidarity. We have to reconstruct solidarity domestically and globally as we come out of the COVID-19 pandemic and as we face climate change. 

So I’ve got, you know, sixteen recommendations broken about—just about equally—five, six, and five—on those targets. We can, you know, talk about those if you want to. But that sort of gives you a sense of the significant agenda that we face if we want to make progress in terms of bringing foreign policy and global health back to the point at which it can support all of our U.S. national interests that we say that we pursue with foreign policy. I’ll stop there. Again, I’m happy to answer specific questions about that, go back and forth on different aspects of this, but that’s just a quick overview. 

HAMBURG: Well, thank you. That was a masterful job summarizing what is a very meaty report, but a report with a set of clear recommendations for action, you know, which I think is very, very valuable. 

Turning now to you, Ashish, you’ve come out of a job where you were right, in the midst of the action, working at the often treacherous interface of health and politics, but doing a job that was absolutely critical for our nation and for the world beyond. I’m sure you have some perspectives, both on what David has had to say but also on some of the other important elements that we need to be thinking about as we prepare for the future. 

JHA: Yeah. So, Peggy, thank you. And thanks, everybody, for having me here. 

I will really try to build on some of David’s points. And I think maybe I will start off in thinking about the four questions you asked David. I’m going to push it towards really thinking about this pandemic. What have we learned? How do we move forward? And I’m going to make a few sort of high-level remarks, and then I’m happy to get more into details in the Q&A. 

First of all, I want to start with dispelling a myth that I hear a lot from folks who often like to say, we’re in even worse shape now than we were four years ago. Like as a country, how prepared we are. In my view, that’s just nonsense. Like we are way better prepared now than we were four years ago. It’s been a very painful path. One-point-two million Americans have died. Like, this is not how we wanted to get here. But we are way better prepared.  

And I’ll give you a few specific examples. Our surveillance system is dramatically better than it was four years ago. We have wastewater surveillance for much of the country that can be used against all sorts of threats. We have rebuilt our strategic national stockpile. We have learned how to build vaccines very, very quickly, and have infrastructure that still remains. Let me be very—also very clear. All of those gains, as important as they are, are fragile. They can all be turned off. And we can very quickly backslide. And the absolute critical goal is to make sure we don’t backside.  

Alright, but given that that’s the positives, I’ll talk just for a minute about some of the challenges that we face where we are going to need bipartisan support in order to rebuild. So I think a lot of the problems, certainly in the early days but to this day continues, are problems of execution and problems of agency capability. Our CDC, our FDA, HHS, ASPR—all of those are agencies that are not, in my view, fully ready to take on the next challenge. And all of them have launched reforms. Certainly, CDC did under Rochelle, it continues now under new leadership. FDA still—I think there are important reforms that have started happening. But those need to continue and those need bipartisan support. 

And, yes, some of it is about resources. A lot of it is not about resources. A lot of it is about building up technical capabilities. A lot of it is changing, really boring processes. The number of times—like, it was very clear to us what the right answer was from a public health point of view, from a political point of view. And it was insanely hard to do, because these agencies have processes that work fine under peacetime, cannot and do not function effectively when you need—when you have an emergency. So think that is something that requires a lot of effort.  

And then the kind of last point is—and David mentions this in his report, and this is another place where I think it’s both treacherous and we need a lot of bipartisan work—is public health largely happens at the state level, right? Cities and states. And that relationship between the federal government, and states, and—when I say cities, I mean big cities like New York and Chicago and others. Essentially function as, you know, almost independent public health agencies. They are independent public health agencies. That relationship really needs to be strengthened and rethought in some ways. And I’m actually—when I think about things that worry me, I worry a lot about backsliding on the—on the relationship between the federal government and states. 

So let me just finish by saying, you know, I think we have—as a country, we’ve shown that there are some extraordinary things that we can do. Yes, more resources are needed for public health. But I find that conversation—a lot of conversations in public health begin with: We need to fund public health better. Like, of course we do. We need more money for public health. But we also need more public health for our money. And our public health agencies need to function more effectively. And I think that agenda of reform needs to really be driven. And that should be a very bipartisan thing. 

Last point, just very quickly. I found in my time in government that I spent a lot of time up on the Hill talking to Republicans and Democrats. I found a remarkable degree of consensus about these kinds of issues. You don’t hear it publicly, but I think the opportunity for improving the U.S.’ capabilities are really substantial, and I think it can garner bipartisan support. 

HAMBURG: Well, thank you very much. And appreciate an injection of some optimism, especially given all of your recent travails. 

Now I’d like to turn to Dr. Linda Fried, our card-carrying public health expert. Is dean of the School of—Columbia School of Public Health. And also a broad thinker on health challenges facing our nation and the world. Linda. 

FRIED: Well, good morning. Thank you so much for the opportunity to join all of you and, David, for the opportunity to read your terrific report. Thank you for that. 

Maybe what I can do is pick up on several comments that each of you made. because I think that as we’re—as we’re considering what the future of global health has been, it’s important to take stock both of what the role of public health needs to be and also how the public health—how the public’s health differs, perhaps, from even what it was in the Spanish flu pandemic. And part of the way we got caught short I think, in COVID, necessitates thinking differently about the pillars of the public’s health. 

Compared to a hundred years ago—and maybe this is too big a stretch—what we saw in this pandemic was that the underlying characteristics of the population, perhaps particularly in the U.S., changed the outcomes of the pandemic. The population is older. We have added thirty years to human life expectancy since then, with all the physiologic vulnerabilities we all incur as we get older. But even middle-aged populations and younger are carrying more chronic disease, more preexisting conditions, and this—and high rates of obesity, all of which lead to high vulnerability to both infection and severe illness. 

And these conditions are, at least on the chronic disease and obesity side, highly preventable. But they require a different kind of game. I think it’s easier to think in terms of motivations of the public and of our leaders about public bads, like pandemics and climate change. Perhaps a little harder to capture the imagination around public goods, like preventing long-term chronic disease. But the challenge here is that all three of those actually mutually affect each other. Climate change causes vulnerabilities for pandemic risk and response. Chronic diseases laid the basis for who got sick—really sick and who died. And pandemics, we saw actually worsened certainly, the chronic disease issues for the population. 

So as we think about the—what Ashish was saying in terms of redesigning our public health system, perhaps particularly at the state and local level, I think we can’t take a stove piped approach and be successful here. And in fact, those three issues are issues not only that mutually affect each other, but that could be pillars of the redesign of a public health system for the future. Because the conditions for prevention could be quite successful on each but have to be delivered at a local and state level.  

The other issues, of course, are that I think we need to recognize what has to be delivered at every level and what the motivations are for the players at those different levels. Perhaps states are more ready to invest in the public goods of long-term keeping the population healthy, but it’s quite essential since the health status of the U.S. is now at the bottom of peer nations. Life expectancy is close to the bottom of peer nations, as it’s been dropping in the last few years. And only part of that drop is during the pandemic. And so the role of the public health system, which is to carry out the definition of public health, the actions we must take collectively to protect all of our health and to promote it, we need to think what needs to be allocated at those different levels, and the motivations for believing in the health of all of us, and recognizing that there’s some things that can only be accomplished together. And then thinking about the key issues that have to be solved globally. 

I’ll stop there. Thank you. 

HAMBURG: Well, thank you very much. A lot of excellent comments. You know, each of you have, I think, underscored that there are some very concrete steps that can be taken that will both improve health and wellbeing today and tomorrow in peacetime, but also position us better to respond to a crisis. And that, you know, we have a very clear and vital national interest in addressing these health problems, these public health concerns, both domestically and internationally. But we also, I think, all recognize the context that we’re in, a context where there is this—you had a quote, actually, that I loved—disrupt and divide mentality, that is quite prevalent and powerful. 

We also live in a world with so many competing priorities and short attention spans. And we’ve seen that in the cycle, vis-à-vis infectious disease threats of crisis and complacency, but it’s also a much broader set of concerns. And then this fundamental issue about trust in critical institutions and critical leaders. I would just like to quickly ask each of you to reflect on, how do we build that fundamental foundation of conviction in our public and our policymakers that we need to do all these sensible, worthwhile and, I believe, achievable things that you’ve outlined? 


FILDER: Yeah. (Laughter.) In formulating recommendations in the report, I found myself coming back to processes, processes, processes. And some of those recommendations might have struck many of you as sort of odd, as they’re not being—they’re not substantive. They’re not about a problem we have with surveillance, or with capability, or surge or—you know. Because part of that, both for security capability and solidarity—and, by solidarity, I mean strengthening that sort of shared political and ethical responsibility for what we’re doing with human health. To rebuild a focus on security, rebuild capability, reconstruct solidarity, I think we’ve got to have processes that encourage that focus on the problem where you can get bipartisan support. 

And this has to happen at the local, state, federal, and global level. So the agenda here is huge. So one of my recommendations was to have what I call health security fusion centers at the state level. And I base this idea on the fusion centers that were created for antiterrorism after 9/11. Not that that is necessarily an example that fits nicely with health, but I had experience working with the fusion center in Indianapolis at the time these things were set up. And you began to see that they were starting to cooperate beyond just counterterrorism. They began to cooperate on other law enforcement issues—drug trafficking, violent crime. 

And you began to—I saw them working on issues together focused on finding solutions for the problem. And I think that’s part of the reason why I focused on having these different processes in place, because we’ve got to rebuild that capability. We’ve got to be ready for emergencies. We’ve got to be able to handle the nonemergency situations on a sustained basis. And so there are a number of the—I’m not going to go into some of the other ones. That’s just one that I think, you know, pops out as we’re talking about the need to strengthen U.S. public health as part of what we need to do also as a domestic source of our foreign policy activity in this realm.  

HAMBURG: Thank you. 


JHA: Yes, I’m going to echo one of David’s points, but kind of build on it. 

So the question is, how do we build back trust in the public health, in our institutions? Yeah, there is no obvious, straightforward set of answers. I think there are a couple of things that will be helpful. One is by acknowledging mistakes. I think it is unfortunate that we are not going to have a 9/11-style commission. I don’t know if that’s the right style, but other countries are doing pretty deep looks into their pandemic response. The U.K. is, New Zealand is, other countries are. I don’t see that happening here in the United States. And I think some effort to look and—both systematically look at what went wrong, acknowledge mistakes, would be very, very helpful. As I said, I think there isn’t going to be a single one, but maybe we can find ways of doing that. 

I think from a public health trust point of view, I think the public health experts—and I certainly put myself in this bucket—made mistakes. And we have to—we should publicly acknowledge them. And I think that also is really important. So I think acknowledging mistakes, identifying problems, being very public about them, I think will be helpful. I think the stuff that is happening, like what’s happening in Congress, not helpful. It is really taking COVID and trying to figure out what’s the most kind of pernicious, partisan way to look at it and divide the country. And I think that is—I think that is not helpful. But so I think that’s sort of one. 

Second is something David said, which I’ve really believed in, which is, you know, people often talk about the best way to fight—or, the best way to prepare for future pandemics is to fight the current challenges better, right? That preparation is not, OK, everybody train up for, like, the next pandemic, which might happen next year, or might happen in twenty years. It is, build the capability for working on really substantive public health challenges at the local level. And that’s when you—once you begin to build trust across agencies, that kind of work makes it so that when there is a crisis that is unexpected, everybody is much, much better prepared to be able to handle that. And I think it also helps build back trust. 

Last point on this is I do think—and I hope, and maybe this is just my optimism, that letting a little bit of time pass is going to help. We saw this—one of the things I did when I was at the White House in January, February of this year is I started calling up historians, people who were historians of medicine and science, with a very simple question, which was: How do pandemics end? What do we know from history? And there were lots of various ideas that people had. But the one thing that everybody brought up was this idea that there is kind of a deep collective amnesia that sets in as pandemics fade. That there is a period of time when nobody wants to talk about it, nobody wants to deal with it. and everybody just wants to put it out of their minds.  

And it’s a very classic trauma response, right? The country just went through a very, very traumatic event. And right now, everybody wants to talk about anything but COVID. And I think that’s OK. Like, I think time will help with that. But for those of us who actually care about making sure that the country’s better prepared and we’re building back trust, there’s work to be done in this time period so that when the nation is ready to engage on these issues a bit more, we have made progress and we have not lost that time. So I think time, ultimately, if we use it wisely, it can be helpful. 

HAMBURG: Thank you. 

I do want to turn to you, Linda. I also want to circle back to some things you just said, Ashish. But I also see that we’re running out of time already. But Linda. 

FRIED: So I think the question of trust is absolutely critical, because how to get people on board with a new vision and goals in a way that they think will be useful for their lives and the people they care about, and that they believe there will be follow-through on, is critical. Otherwise, nothing can be done. And, of course, I always feel like public health should be the exemplar of the fact that we’re all in this together. That’s really what it’s about, is the recognition of that. (Laughs.) And it’s about getting—keeping people from getting sick in the first place. And those are public health’s responsibilities. 

And so building on, I think, what Ashish just said, it might be a good time to really lead from conversations about what we’re all in together on, the things that are not the responsibility of the individual nor the capability of the individual to solve solo, but that are harming people. And then the—and maybe the places to start are our children. So how to protect children against the health impacts of climate change, a critical thing we need to do whether it’s wildfires, extreme heat, hurricanes, et cetera, drought, food insecurity, and changing safety of the water in the face of changing pH due to increased carbon dioxide and warming temperatures. Protecting human health in our local communities in the face of these conditions I think is a first line of where to focus. Whether we want to use the words “climate change” or not, the reality is that conditions are changing. And public health has to be the front line on that. 

Similarly, how do we—and that’s the most vulnerable populations, of course, are children and older people. Air pollution, a critical issue that gets worse in the face of climate change. But also how do we deal with obesity? It requires a collective community agreement to invest in resolving food insecurity and putting healthy food in front of children in the school—in schools as long-term investments and making healthy food available and affordable ways in communities. Those two things alone would be, I think, pro-social goals if they were accompanied by the constant community-level discussion and narrative of what this bulwark of protection could mean that we could accomplish together. 

Those are ways perhaps, Ashish, to get—to let the pandemic mentality and trauma be resolved, while we actually put in place a framework of preventing chronic disease and preventing the health impacts of climate change that could then be mobilized in the face of a pandemic. And then, of course, we have to inspire and train the next generation of public health workforce. I will also say there are silent things that needs to be done or can’t carry out this agenda. The causes of obesity are a perfect storm of factors of the changes in the conditions of people’s lives on an ongoing basis. Some of that is driven by the subsidization by—through the federal government, USDA, of corn products, for example, which is anachronistic at this point. And those quiet things could be resolved to, in fact, make other kinds of food healthier and more affordable. 

HAMBURG: Well, thank you. 

Well, I do think we should open up it to the audience—or, the members for questions and comments. We’ve got some real experts here to help us build on the conversation so far. I saw, Rebecca, your request to take the first question. So I’ll turn to you. And I’ll also recognize that that you were a co-author of another very recent CFR report that I think contributes to our understanding of this area, that was really focused on the challenges of global governance for health. But, Rebecca. 

Q: Thanks, Peggy. 

First. I’m deeply appreciative of David’s report. He knows I’ve already made it assigned—required reading for my class. And I think it starts a really important discussion that’s not often had around the foreign policy implications and opportunities. 

I’m going to respectfully disagree with one of Ashish’s comments. I’m actually deeply concerned about where we are right now in our ability to effectively respond to an infectious disease outbreak. I absolutely agree that I think that there’s a lot of really exciting innovation and capacity that’s being built, but I—what you—maybe what you call the boring processes are the things that I think a lot about. And I think they’re the make and break. And I think at the—at the state level we’re watching—we’re watching states change their executive power and take it out of the—out of the hands of the executive and into a slower legislative process, which I think is going to tie our hands behind our backs. 

And I—at the—at the global level, think we have a lot of states that are kind of reconsidering—who are not trusting our current multilateral system. And this, I think, gets back to maybe some of David’s points about what do we do about that. And is the—is the solution to strengthen multilateralism, or minilateralism, or whatever we’re going to do? But I think the situation we’re left and right now is that there is a lot of distrust amongst nations, for good reason. And we could have the coolest surveillance systems in the world, but if countries refuse to share information, as their sovereign right, we’re going to—we’re going to be flying blind.  

So, anyway, I think that there’s—I think there’s a really interesting opportunity and a right moment to be thinking about the foreign policy implications around how do we think about the political issues at the same time the public health community, you know, goes into our corner when nobody’s looking and does everything we can to build capacity. So it’s more of more of a comment. 

HAMBURG: Well, thank you. And, Ashish, I’m sure you’d like a chance to— 

JHA: Very quickly. So I totally agree. I don’t know that we disagree at all. What I said was, and I believe, is that there’s a set of capabilities that we have now that we did not four years ago. And that is really important. I also think those are fragile, and those alone can be pulled back very, very quickly. And they actually need active work not to be pulled back on. Some of the most important gains that I think we’ve made in the pandemic would all go away tomorrow if there was not an administration fighting tooth and nail to keep them going. And that worries me. 

And then there’s absolutely no question that the boring processes are fundamental. Like, basically the fact that you needed—the Trump administration had a coordinator coordinating this out of the White House, the Biden administration had two, is a reflection that our agencies can’t quite manage this stuff on their own. And this is not to question their—the amazing people who work in those agencies. That stuff absolutely needs to get done. So I don’t—I don’t mean to sound like things are great, we’re in good shape, nothing to worry about. We have really hard work to do. I just—I think it’s important that where we have made progress, we acknowledge it, because otherwise we will not sustain it. 

HAMBURG: Thank you. Tom. 

Q: Great. I’m Tom Bollyky here at the Council. 

Let me start by also congratulating David for his report. It’s trenchant. It’s clear-eyed. It’s cleanly written. We’re very fortunate to have David at the Council. 

I want to press David a little bit, though, on one of the framings of this argument, and then I want to ask a question to Ashish and Linda. The question for David, or press to refine the argument, is you make the point, I think rightly, that our global health investments were sold in a number of ways. They were sold that they would promote democracy, they would build economic capability, U.S. national security interests. But they weren’t actually designed that way. We do not fund democracies more than autocracies. We did not fund the health conditions that cause more economic burden. We didn’t fund the health causes that are the greatest national security risks to the U.S. And we, of course, didn’t fund them well. 

So I guess what I’m asking, is the issue here that we sold these inappropriately, and that has led to disillusionment? And then the question is, can we be more real realistic about what these programs are doing in the future, or are meant to do? Or is it a question of the programs themselves being changed so that they might be able to accomplish the original goals set out for them? Because it seems to me to be not quite right to think that these programs failed at objectives that were designed to actually do.  

For Ashish, and I think this is inspired by your comments but I imagined Linda might have some responses too, is you talked about all these great capabilities, particularly around vaccines and surveillance system. The U.S., of course, did get vaccines within 326 days from the original identification of the genetic sequence. We still struggled relative to other high-income countries. Even when you control for the relevant biological factors, there’s a fourfold difference between how states performed in this country.  

And I guess this comes down to implementation and leadership. And I wonder, you know, some of this is doing the hard work of making government institutions trustworthy, but are there policy solutions? You know, people talk about policy triggers and linking in into surveillance. Is there anything we can do to bake this into the system in a way that it’s not tied to the vagaries of elections? Or does this ultimately really come down to the quality of people we put in leadership roles? 

HAMBURG: Thank you. Ashish and then Linda. 

JHA: Well, David first, right? 

HAMBURG: Oh, OK. Yeah. 

JHA: Just to respond to— 


FIDLER: No, I think, you know, Tom’s got a great point. And this is something that I think brings up the question as we move forward, how are we now going to frame global health initiative programs that we want to pursue? I had a lot of difficulty applying all the ways in which we said we were going to hit national interests with global health programs at a time where some of those arguments didn’t make a whole lot of sense. Because, I mean, for example, global health produces soft power, smart power. Well, we were making these at a time where there wasn’t any competition for hard or soft power. I mean, it was, like, what are—we wouldn’t know whether those arguments and how we were designing programs matched up until there was a test of those arguments against what we had designed versus what was happening in the international system. 

And that really started to happen well before the pandemic. And so I think that mismatch between what we’re saying and how we’re designing things is something we’ve really got to focus on. And maybe we need to stop making some arguments that just rolled off my lips. (Laughs.) You know, fifteen, twenty years ago—I mean, we were all making these—we didn’t know, right? It was a completely different world than the one we’re in now. But I think this issue that you pointed out is critical as we try to think about how we make progress going forward. And I’m not really sure my recommendations really get to that point. But I think that’s something that we need to continue to think about. 

JHA: A couple of thoughts, Tom, to your—to your provocative and really important question. You know, there are things you can do from a policy point of view to kind of bake in more effective responses. So one of the things that we saw, I saw it in my time at the White House, is you could see basically misinformation events coming. You could see that there’s going to be a meeting of the—ACD, the advisory committee to CDC. And based on the agenda, you knew exactly where the misinformationists were going to take that meeting. And we would watch it, and then it would happen, and then the misinformation would spread. And essentially, the U.S. government was paralyzed and incapable of responding. And four weeks later, the CDC would put out a statement saying that misinformation is all bad. And, like, the world has moved on. And all the damage has been done.  

So one of the things that we worked on doing—and, again, this is just one part of the solution but starts getting at some of the issues you’re talking about—is the idea—and why did it take four weeks? Because CDC has a process, and information needs to be cleared, the experts have to weigh in. So we started doing a whole bunch of preclearance stuff, where we could see things coming, we had experts put a response together, precleared it, and so when the misinformation event happened, you could respond immediately. That kind of capability is not that hard to actually instill. It’s kind of boring stuff. But it’s absolutely essential in making the government more effective.  

There is a whole set of things that we need to be doing like that, where we know what the problem will be. It may never happen. If that misinformation event never happened people feel like, well, that was wasted work. It’s not wasted work. It’s just a different way of working. So I do think there are things like that, that we can do. You know, in terms of your—the issue of the fourfold difference in mortality, this is a source of some pain for me in the following way. You know, I was at a dinner last week with Jacinda Ardern, who’s the former prime minister of New Zealand. And I was chatting with her about New Zealand’s response. And asked her a question, which was, you know, there was a lot of political infighting in every country about the pandemic response.  

And I said, did different political parties in New Zealand have different views on the vaccine? And the answer was no. Like, it is—one of the things that has really made—like, why does the U.K. do so much—has it done so much better on deaths over the last year and a half compared to the U.S.? It’s because they get their elderly vaccinated. Why? Because, A, they have NHS. But, B, there is no partisan split in the U.K., there’s no partisan split in many countries about things like vaccines. We have managed to partisanize vaccines in a way that is deeply, deeply painful to me, because it’s been one of the most nonpartisan things. I always remind people, the most vaccinated state in the country for childhood vaccinations for years if not decades was Mississippi. And there was no red-blue divide on childhood vaccinations. And so we have got to figure out how to departisanize a lot of these public health things. And vaccines are at the top of that list. 

HAMBURG: Thank you. 

Linda, any thoughts you’d like to share on this? 

FRIED: Yes. Well, first, I wholeheartedly agree with Ashish that a critical leading answer has to be getting the communication, not just right but agile, and staying—and owning the issues at every level. Being able to take the lead on it. That’s critical. And not only addressing the particular issue, but using it to support an over-narrative that we’re all in this one together. All of the principles of collective action are wrapped in these kinds of things. And we should be talking about the fact that we are all of—not skirting the issues of what it means to have a society where—that enables collective action that protects people. Ardern did that beautifully all the way through the pandemic, to my observation. 

But the other thing is that I think this goes to the core issue of what a public good is. And the issues that raise all boats, the things we invest in, because the private sector can’t make a profit on it but it improves just everybody’s lives, and the quality of our lives as well as our health and wellbeing. Public health is front line as a public good. And therefore, is always—quoting Adam Smith—always in jeopardy being under-invested in. (Laughs.) But it requires, I think, two things.  

One is staying—taking it out of the—really intentionally, working on what Ashish said, to get it out of the partisan lane. And the communication is going to have to accomplish people’s willingness to think about it that way, maybe, on these things. And then, actually not being fickle in terms of how we carry it out one day versus the next. And I would say that we’ve been fickle globally in a lot of ways, as well as having too much variation locally and nationally. Thank you. 

HAMBURG: Well, thank you. 

And we have little time. I’ve just been told that we have a virtual question, a member. Why don’t we turn to that quickly? And then I have noted the two here. But we’ll have to do short answers and short questions. 

OPERATOR: We’ll take our next question from Josh Busby. 

Q: Yeah, can you hear me? 

JHA: Yes. 

Q: Great. 

I haven’t heard much discussion thus far of PEPFAR, which for twenty years has been a central symbol of U.S. global health solidarity, buoyed by bipartisan support, which now is under threat as the program struggles to get reauthorized. How do you see PEPFAR’s place in wider U.S. global health priorities? And if you can comment on its status going forward? 

HAMBURG: Well, you know, you must be a mind reader, because I was going to ask a question about PEPFAR just now, stimulated by this discussion, but I wanted to turn to members for their questions. But I mean, it is, you know, something that stands out in terms of global health programs that that have been important components of our foreign policy, where we harnessed scientific advances available in this country to help address a serious and growing health risk in other parts of the world, but that actually benefited U.S. interests in terms of enhancing security, economic stability, development, and humanitarian issues around the world, or in PEPFAR countries. So I don’t know. David, I’m sure that you have some important perspective on this. 

FIDLER: Yeah. I mean, one of the things that we did do beautifully was PEPFAR. Part of the problem, though, when you look at the range of U.S. national interests is that we didn’t—we weren’t prepared for a pandemic, and we’re not ready for climate change. Those are the two greatest threats to our national interest in health. And so we can celebrate PEPFAR, but also step back and say: We’ve got other things that we need to do. 

Second question, do we need to continue PEPFAR as it has operated successfully for decades? Or do we need to begin to reform and modify PEPFAR? Not necessarily just to protect our security or just to deal with climate change adaptation but, again, this is a moment of transformation. We need to think about PEPFAR. And I think that thinking was beginning to happen. Now we’re stuck with a completely different issue, where it’s been linked to an anti-abortion agenda and the reauthorization and maybe the entire program is threatened by that.  

But it doesn’t mean that the success of PEPFAR over those decades removes it from the need to rethink what we’re doing here. It may be that the decision is we keep going with how we’ve done it before, because that is what it has been successful doing. And that served some of our national interests. We’re not going to make any more geopolitical arguments about how important it is in that field, because it isn’t. But it’s important for these purposes. I think that that could be one outcome of the rethink. 

HAMBURG: Well, certainly PEPFAR has been trying to expand its capacity and its role on some broader global health concerns. But I think what’s happening right now with PEPFAR is an example of the disrupt and divide phenomenon that that creates such fragility in programs that, in fact, have been historically successful, bipartisan, and making a difference.  

Because we barely have any time, let me turn to Mark. And if you could just identify who you are and who you’re affiliated with. 

Q: I’m Mark Lagon. I’m with Friends of the Global Fight Against AIDS, Tuberculosis, and Malaria, and at Georgetown University. David, thanks for all your work, and thanks for what you do here.  

How can we get—how might we get the climate change dimension of this wrong? I don’t mean the problem of Republicans, their motivation to work on climate change, or resources. But what are ways that we could, David, make the wrong step, contributing to siloing or talking about the public health threat and ending up mobilizing the funding for dealing with climate change, but not actually strengthening all these assets that Jha and others here have mentioned? 

FIDLER: Yeah, and one of the things that we could—we could do here is to try to replicate the success we had with PEPFAR. So the climate change adaptation program, PREPARE, that’s an acronym, looks to me like it’s modeled on that. It’s an emergency plan for adaptation and resilience, that’s modeled on PEPFAR. Maybe that’s not the right approach to take with this. Maybe we need to start building-in climate change adaptation across programs that we’re doing in global health. It’s one of the reasons why I make this sort of, I don’t know if it’s a nonsensical recommendation, about turning the global health security agenda into a global health security alliance. I’m not just talking about infectious diseases here. I’m talking about climate change adaptation as something that elevating that coalition that already exists, has success, building in climate change adaptation rather than having a presidential emergency plan for adaptation. We begin to do this horizontally, not vertically. 

HAMBURG: Well, thank you. And I—we had another question, but we have run out of time. And CFR is committed to sticking to the timeframe, in recognition of the importance of all the work you’re doing outside of these walls. But I really want to begin by thanking our panelists for their contributions to our discussion today, and David for creating the report that was the catalyst for this panel. And will be the catalyst for much ongoing discussion and, hopefully, thoughtful, informed action. I’m sure that here at CFR we’ll come back to many aspects of this discussion in other panels and other convenings.  

But I want to thank all of you, not just the speakers, for joining this session. And I should note that the video and transcript of today’s meeting will be placed up on the CFR’s website. So I wish you all the best. And I hope that we will continue to work together to address these really vital challenges before us. Thank you. 

JHA: Thank you. (Applause.) 


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