WHO and PEPFAR Are Good. Leaving Them Is Bad. Any Questions?

22 January 2017, 2250 EST

In the words of Seth Meyers and Amy Poehler from Donald Trump’s favorite television show, “Really!?!

Shortly after noon Eastern time in Washington, Donald Trump gave his inaugural address. In it, he proclaimed his desire “to free the Earth from the miseries of disease.” That’s not a bad sentiment. Health is important, the US has played a major role in developing and funding the global health system that currently exists, and there are a host of health challenges that continue to bedevil the world. Trump has made ambiguous statements about his global health commitments in the past, so this is seemingly a good sign. Right?

Less than two days later, news comes out that Rep. Mike Rogers (R-AL) introduced H.R. 193 to the House of Representatives on January 3rd. Named the American Sovereignty Restoration Act of 2017, the bill would end the US’ membership in the United Nations and deny any funding to the UN and its affiliated organization. It also specifically cites that the United States would, if H.R. 193 passed, withdraw from the World Health Organization.

It’s more than a little disconcerting to go from the president making a speech where he publicly emphasizes the importance of global health to finding out that one of his allies wants to take the US out of the intergovernmental organization whose entire existence is predicated upon promoting global health. (In fairness, Trump didn’t actually write his speech—even after Tweeting out a picture showing him “writing my inaugural address.”)

This is just another in a line of actions that hammer home that the Trump Administration lacks any real commitment to global health. The New York Times reported earlier this month that members of Trump’s transition team had been sending questionnaires to State Department officials that suggest a scepticism (if not hostility) toward foreign aid to Africa and health programs. In particular, the questionnaire provocatively raised doubts about PEPFAR.

Created in 2003, PEPFAR is the largest single program for global health ever created. It was first announced during George W. Bush’s 2003 State of the Union address—a five-year, $15 billion dollar program with an ambitious plan to prevent 7 million new HIV infections, treat 2 million HIV-positive people, and care for 10 million HIV-positive individuals and orphans. It also included $1 billion for the Global Fund to Fight AIDS, Tuberculosis, and Malaria—one of the most important multilateral funding sources for HIV/AIDS. PEPFAR was renewed in 2008 and 2013, and has provided more than $72 billion in funding. Its accomplishments are staggering, both in terms of its treatment and prevention successes and its demonstration of the United States’ commitment to global health.

In fact, at the very same time that Trump transition officials were questioning State Department officials about the efficacy of PEPFAR, Rex Tillerson—the very man that Trump has nominated to lead the State Department—was praising PEPFAR as “one of the most extraordinarily successful programs in Africa” and cited how PEPFAR’s work assisted ExxonMobil’s own efforts to treat and prevent malaria in Africa. This is hardly the first case where one of Trump’s Cabinet nominees has contradicted Trump’s own statements and policy view, but the ambiguity over the Trump Administration’s direction in global health (and foreign policy writ large) will unsettle future planning.

This is exactly the wrong time for uncertainty coming from the largest provider of global health aid. The World Health Organization is on the verge of electing a new Director-General. The United Nations and World Health Organization are working on plans for reforming how the international community responds to outbreaks so that it can do better than its Ebola response. The world is still grappling with how best to respond to diseases like Zika, but repealing the Affordable Care Act could cut the Centers for Disease Control and Prevention budget by 12 percent—including funds that help states devise plans for pandemic threat responses.

At a time when we need more cooperation to address the health threats facing international society, the Trump Administration is threatening to withdraw. That will give infectious disease the upper hand and put all of us at greater risk.

Given this dire situation, how do we convince the Trump Administration to remain engaged with global health? One strategy might be to appeal to national security and economic interests. Treating and preventing infectious diseases in other countries leads to greater stability and more economic prosperity. ExxonMobil’s interest in malaria is driven less by its altruism and more by its commercial imperatives; higher rates of malaria among its workers leads to less productivity.

As I’ve written before, this strategy brings its own risks with it, but it may fit in with Trump’s worldview. Remember his tweets about Ebola and how the government needed to keep it out of the US? One effective way of keeping people from fleeing their home countries is to make sure that they can get effective treatment and care where they live.

Another strategy is to appeal to Trump’s business side. Every dollar that gets invested in water and sanitation—key strategies for preventing the spread of infectious disease—provides a return of $4.30. Each dollar invested in disaster preparedness saves $7 in disaster recovery and aftermath. What great returns on investment! What a smart businessman to make such investments! Working together with other countries makes our money go further and helps us achieve the goal of ending the miseries of disease. See? Everyone’s a winner!

Pulling the US out of WHO won’t save tons of money. It won’t make the world safer or healthier. It’s a recipe for chaos, confusion, and the greater spread of infectious disease. It’d be worse than Ashlee Simpson’s lip syncing debacle on Trump’s beloved SNL.