In November of last year Republican Donald Trump was elected as the next President of the United States. The upset victory was a surprise, given that most major polls showed his opponent on the left, Democrat Hillary Clinton, with a comfortable lead going into Election Day. The consensus seemed to be that a Hillary Clinton presidency would mean the continuation of many of the Obama administration’s policies. This was especially expected in the area of global health. As Obama’s first Secretary of State (2009-2013), Ms Clinton oversaw much of the US investment in global health, including its contribution to the Global Fund and the President’s Emergency Plan for AIDS Relief (PEPFAR). In addition, through the Bill, Hillary & Chelsea Clinton Foundation (The Clinton Foundation) and the associated Clinton Health Access Initiative (CHAI), Ms Clinton had a relatively strong familiarity with global health programs and imperatives, and a history of supportive engagement in them.
Donald Trump & Mike Pence
However, Ms Clinton did not prevail. And rather than a continuation of the Obama years, Mr Trump was elected with a message of utter rejection of Obama’s policies. Mr Trump campaigned on messages of American protectionism, the deportation of millions of immigrants, the registering and monitoring of Muslims, and the destruction of Obama’s signature legislation: the 2010 Affordable Care Act, or “Obamacare,” which has already been embarked upon by the Republican congress. During the campaign Trump betrayed a superficial grasp of foreign policy, which was generally limited to ideas of increasing American military might and the condemnation of countries over economic concerns. He also made clear his admiration of Russian president Vladimir Putin, whose record on global health, human rights, and democracy is singularly bad.
Thus major questions loom over the future of US global health policy—and just about everything else. Mr Trump is a political outsider who has never run for or held elected office, and who has been known to change his mind frequently. While some of the biggest questions will probably take time to answer, there are some statements and early actions of the President-elect which are worth looking at.
Global health in the election
Discussion of the United States’ leadership role in global health barely surfaced in the presidential election, particularly on the Republican side. When it did, discussion tended towards lamentations of US spending in other countries, given the Republican orthodoxy of cutting government spending in recent years. In perhaps the only instance of a direct comment on global health, in October 2015 Mr Trump addressed a question about whether or not he would continue the investment in PEPFAR: “Yes, I believe so strongly in that, and we’re going to lead the way.” While this statement may give some comfort to global health advocates, it is important to remember that Mr Trump’s style involves a lot of saying whatever feels right at the moment.
There may be some sound reasons the issue of aid did not come up much. First, foreign aid is actually a marginal amount for the US government: less than one-percent of the $4 trillion federal budget. Secondly, and perhaps most importantly, foreign aid has historically received strong support from both Republican and Democratic presidents and legislatures, and thus does not represent an area of great contrast between candidates.
Trump's big picks
The most important cabinet role with regard to global health is the Secretary of State, which oversees the US Agency for International Development (USAID), PEPFAR (and its head, the Global AIDS Coordinator). The Secretary of State is also the highest-ranking cabinet member after the Vice President. Mr Trump has nominated former Exxon-Mobile CEO Rex Tillerson. The former oilman doesn’t have much of a record on global health, which could be both an obvious liability and an opening, in that his approach could still be shaped by experts in the field.
Because Tillerson, who is currently undergoing confirmation hearings, doesn’t have a lot of experience in global health, it may be all the more important who is appointed to other more focused roles, such as the Global AIDS Coordinator and Ambassador-at-Large. This office, most recently held by longtime AIDS advocate and physician Deborah L. Birx, is in charge of all US engagement with the Global Fund, administers PEPFAR, and coordinates aid with other governments. Current Global Fund Executive Director Mark Dybul held this position for several years (2006-2008) under the George W. Bush administration. However, it is unclear if Mr Trump is interested in continuing it the office or whom he would pick to occupy it.
Another pick that has direct relevance for global health is the Secretary of Health and Human Services. While it is true that the Department of Health and Human Services (DHHS) is mostly focused on domestic programs like Medicare (insurance for the elderly), Medicaid (insurance for the poor), and aspects of “Obamacare,” there are many international programs as well, such as through the Centers for Disease Control and Prevention (CDC) and research projects funded by the National Institutes of Health, among others. In fact, nearly all US investments in health research would go through DHHS. President-elect Trump announced in November his selection of Tom Price to be the Secretary of Health and Human Services. Mr Price is a Republican member of the House of Representatives from Georgia, a generally conservative state. As the New York Times reported: “If President-elect Donald J. Trump wanted a cabinet secretary who could help him dismantle and replace President Obama’s health care law, he could not have found anyone more prepared than … Tom Price….” Mr Price is expected to undergo successful confirmation hearings over the coming weeks.
Donald Trump’s running-mate, Vice President-elect Mike Pence is a bit of a contradiction when it comes to global health funding. On the one hand, when he was in congress (as Republican Representative of Indiana) he was a vocal champion for PEPFAR, saying that, “PEPFAR put the world on notice that America will not ignore despair and desperation. It has shown the world that America is committed to bettering the lives of people around the globe, especially in Africa, who suffer from HIV/AIDS.” On the other hand, as a hardline social conservative Pence has fought to curb the rights of LGBTQ Americans and defended the early provisions in PEPFAR which restricted funding from sexual and reproductive health and rights programs and required that funding recipients focus on abstinence as the primary means of HIV prevention.
Domestically, Mr Pence’s track record is more clearly problematic with regard to HIV. As Indiana’s Governor in 2015, he presided over “the worst HIV outbreak in its history,” according to the Washington Post. Then-Governor Pence’s strong opposition to needle-exchange programs—they were illegal in Indiana—and defunding of health care providers like Planned Parenthood were linked to a rapid increase in HIV infections among people who injected drugs in rural Indiana. Pence infamously dragged his feet on allowing harm reduction services as infections mounted and the CDC was dispatched to manage the outbreak, before ultimately allowing “temporary” needle-exchange programs in a handful of Indiana counties.
Bi-partisan and public support, and a strong case
Despite all the big questions surrounding the US’s role in the world moving forward, it is worth noting that foreign assistance, and particularly health-related aid such as PEPFAR and the Global Fund, has retained strong bi-partisan support through Republican and Democratic congresses and presidencies. In fact it was during Republican president George W. Bush’s administration when both the Global Fund and PEPFAR were launched. The American public has also indicated strong support for international health investments. As noted in a previous GFO article, a 2015 Kaiser Family Foundation poll found that more than two-thirds of Americans supported US involvement in global health initiatives. Moreover, as Nancy Birdsall and Alan Gelb pointed out in the Center for Global Development blog: “US foreign aid spending has been higher when a single party controlled both the White House and Congress, and in that situation higher with the Republican party.” Nonetheless, there is talk among Trump advisers about changes in foreign aid, including Newt Gingrich, who said in December that US aid needs to be “very dramatically overhauled.”
Nonetheless, as Chris Collins, President of Friends of the Global Fight, importantly points out, “The election didn’t change the fact that the Global Fund is a hugely effective investment for the US.” And that is exactly what he thinks advocates should be focused on: continuing to the make the evidence-based case that investments in global health are sound, smart, and good for America, just as they save lives around the world.