Introduction
The election and subsequent inauguration of Donald J. Trump as the 45th President of the United States of America (US) in 2017 was met by the global health community with shock and concern. The shock was over how a person who spoke of pussy grabbing, publicly criticised politicians and world leaders on Twitter, loosely engaged with facts in using statistics to justify his statements, and engaged in dog-whistle racism such as accusing all Mexican migrants of being criminals and rapists was deemed presidential by the US electorate.Footnote 1 Global health practitioners and policymakers tend to come from public health, clinical, or health economist backgrounds and therefore see political decision-making in a narrow schema of rational choice and evidence-based decision-making.Footnote 2 For this community, there was no rational evidence base for why Trump would be better at delivering on the electoral concerns of the population – employment, wealth creation, security – than Hillary Rodham Clinton. Compounding such disbelief was the sense that Clinton was an ally of the global health community given her, now allegedly controversial, links to the William J. Clinton Foundation and her daughter Chelsea Clinton’s work as a global health scholar.Footnote 3 The concern was about Trump’s campaign commitments to repeal the US Affordable Care Act, or ‘Obamacare’ as it is popularly known, his appeal to the right of the Republican Party on Reproductive Rights and access to abortion in the US and overseas, and his dubious use of knowledge, evidence, and fact.Footnote 4 For publications such as The British Medical Journal, ‘The Trump administration’s early policies risk head-on collision with the scientific and health communities.’Footnote 5 These concerns were not expressed formally by the leaders of global health institutions such as the World Health Organisation (WHO) or the World Bank. The World Bank has not spoken out on such issues and in July 2017 announced its new US $325 million ‘The Women Entrepreneurs Finance Initiative’, in partnership with Trump’s daughter Ivanka Trump.Footnote 6 Instead these concerns were expressed in the editorial and comments pages of leading global health journals such as The Lancet, The Journal of the American Medical Association (JAMA), and the British Medical Journal (BMJ). Concerns came from researchers, experts, journalists, and noted global health leaders, such as Bill and Melinda Gates.Footnote 7
The concerns expressed by the global health community at the outset of the Trump’s presidency were perhaps well founded. In his first week in office he signed an Executive Order to reimplement the Mexico City Policy, known as the ‘global gag rule’ on abortion services provided by US aid, and his March budget outlined substantial funding cuts to the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), and the United Nations (UN).Footnote 8 Trump’s presidency began with concern and surprise from the global health community, but developed into Trump becoming a totemic figure in which to project all of global health’s problems and insecurities. We agree with much of the global health community’s criticism of the Trump presidency. However, we argue that Trump’s presidency holds an uncomfortable mirror to pre-existing inequalities within the global health community and is somewhat of a displacement activity to avoid a critical engagement with the existing shortcomings in global health governance. Unfettered access to sexual and reproductive rights, sustained financing of health system strengthening initiatives, affordable medicines and vaccines, and a human security-centred definition of global health security were already problematic shortfalls in global health governance. Trump’s arrival no doubt exacerbates these concerns, however, to blame his presidency for failings in these areas ignores the issues that have been endemic to global health governance prior to his presidency.
We make this argument by exploring three US-led global health initiatives of concern under Trump’s presidency. We do not explore the impact of Trump on health policy in the US, but focus on global health governance. Global health governance refers to ‘trans-border agreements of initiatives between states and/or non-state actors to the control of public health and infectious disease and the protection of people from health risks or threats’, it involves multilateral and bilateral agencies, scientific and public health epistemic communities, private philanthropists, the private sector and public-private initiatives, and a range of community and international non-governmental organisations.Footnote 9 US engagement and reach in global health governance has been comprehensive, but in the three following areas Trump’s leadership has come under particular attention. First, we consider one of the greatest criticisms of the Trump presidency – curtailment of access to and recognition of reproductive rights as a consequence of the Mexico City policy ‘global gag’ rule. Second, we explore the fear of funding cuts to US investment in global health, with particular reference to the president’s Emergency Plan for AIDS Relief (PEPFAR). Finally, we consider the relationship between Trump, global health security, and pandemic preparedness. The article concludes by reflecting on what the Trump presidency tells us about global health governance.
Concern 1: Reproductive health and the global gag rule
The Mexico City Policy, or ‘global gag’ rule as it is commonly referred to, was first introduced by President Ronald Reagan in 1984. The policy prevents any non-governmental organisation (NGO) engaged in abortion services, advice, advocacy, or referral from receiving US funding, even if such activities are funded with non-US money.Footnote 10 Hence not only would no US funds be used for these services, no NGO involved in these activities would be able to receive US funding for other aspects of their work. For example, if an international NGO provided abortion counselling in Guatemala the same international NGO would not be able to receive US funds for HIV prevention work in Ghana. Trump’s executive order to reinstate the policy extends previous versions to encompass both US bilateral aid and all ‘global health assistance furnished by all departments or agencies’.Footnote 11 The scope is thus much broader than previous versions in its inclusion of agencies such as the CDC and FDA and UN agencies, and could thus potentially have much deeper impact on reproductive health.Footnote 12
Critics of the global gag rule commonly focus on two factors. The first, is that historically the gag has not reduced the number of abortions in the world, and therefore fails in intent.Footnote 13 Evidence suggests that ‘highly restrictive abortion laws are not associated with lower abortion rates’.Footnote 14 The global gag may fulfil its initial aim of the US taxpayer not funding abortions overseas, but exacerbates the problem by contributing to a rise in unwanted pregnancy and unsafe abortions. The second is that the gag will have significant consequences for women’s access to safe abortions and wider forms of reproductive care and sexual health provision, including HIV/AIDS provision.Footnote 15 Access to reproductive rights in choosing how to manage your reproductive health is a key component of reducing the 308,000 deaths from childbirth every year, and preventing pregnancy being the leading cause of death of females aged 15–19.Footnote 16 According to The Lancet, ‘84% of all unintended pregnancies in developing regions occur in women who had an unmet and need for modern methods of contraception’.Footnote 17
The only potential caveat to the global gag rule is how it works in implementation. Implementation depends on the full staffing and briefing of the State Department and USAID and the in-country offices, which one year one into Trump’s presidency have continued gaps in administration or only interim leaders in place.Footnote 18 In addition, there is little guidance from the Trump administration as to how government agencies interpret the order.Footnote 19 This will slow down the pace of change and implementation, particularly when those working in-country may have differing political views on the gag rule and thus lack personal political incentive to implement it quickly or in full. The policy will come up against legal protection for women’s reproductive rights in states such as South Africa where US funding has partnered the government in providing key services for the prevention of HIV.Footnote 20 This has been evident in previous attempts to implement the gag when some foreign states were immune because of diplomatic reasons and US NGOs were exempt because of the constitutional challenge it posed.Footnote 21 The policy will also confront multilateral commitments made at UN conferences to ensure and protect women’s reproductive health such as the 1994 Cairo International Conference on Population and Development.Footnote 22 The reintroduction of the global gag rule has provided an opportunity for other states ‘to show global leadership’ in this area.Footnote 23 The Netherlands government initiated an international safe abortion fund to ‘plug’ the $600 million gap caused by the US government’s funding withdrawal; they received pledges from twenty governments and private philanthropies within a fortnight.Footnote 24 However, the concern with Trump’s action is that the US-funded policy empowers politicians in countries who continue to support the criminalisation of abortion and abortion services.
Control of women’s bodies and reproductive health choices is nothing new to US global health policy or global health governance. The gag fulfils the wider aim of Trump using a key flagship policy to appeal to voters on the right of the Republican Party. Trump’s executive order to re-enact the global gag is for some a form of ‘political theatre’ to appease his ‘paleo conservative’ supporters.Footnote 25 As Joseph Frankel states, ‘every Republican president since Reagan has enacted some form of the rule, and every Democratic president has undone it’.Footnote 26 The global gag rule is thus embedded in not only partisan politics, but a wider pattern of controlling women’s bodies and their reproductive choices to gain political favour.
Attempts to fully integrate reproductive rights into global health governance and wider international development agendas have historically been limited by conservative US administrations and governments from around the world, and most notably the Vatican within the United Nations General Assembly. According to the Center for Reproductive Rights, as of 2014 only three states in South America and two in Africa allow abortion without restriction.Footnote 27 Globally, according to a 2014 study, abortion is prohibited or only allowed in cases to save a woman’s life in 66 states; a further 59 countries only permit abortion to ‘preserve health’. In contrast, 61 countries permit abortion ‘without restriction as to reason’. While improving maternal health was Goal 5 of the UN Millennium Development Goals and a key indicator of Goal 3 of the Sustainable Development Goals, the language of reproductive rights are not included in wider discussions about maternal health. The emphasis has been on women’s access to antenatal care and prevention of death in childbirth rather than control of their bodies and choice as to when or whether to become mothers.Footnote 28 Trump and the US government therefore align to the global norm of restricting rather than enabling reproductive rights. The Trump era is a repeat of the Bush and Reagan presidencies and, tragically, these domestic changes of government have had a huge influence on the progress of global reproductive rights. Normative frameworks for enabling reproductive rights may exist through UN conferences, however, state adoption and practice suggests the dominant competing norm is to restrict rather than enable reproductive rights.
If 308,000 men died every year in childbirth for preventable reasons the conversation about reproductive rights may be different. Trump did not invent the patriarchy but has a powerful role in advancing it. Global health governance has been weak in advancing reproductive rights and challenging patriarchal attitudes to women’s bodies. This is in part because of the problematic way in which gender concerns are framed as women’s health and often reduced to maternal and newborn child mortality, and partly because reproductive health and rights appear too political to challenge member states on.Footnote 29 It is notable that aside from the United Nations Population Fund (UNFPA), one of the only prominent actors in global health governance that has attempted to advance reproductive health is the Bill and Melinda Gates Foundation.Footnote 30 In the main, attempts to address reproductive health have been curtailed by the global norm of restriction rather than access. Trump is just adhering to the norm.
The alignment of Trump to the global norm of restricting women’s access to reproductive rights offers a potential backlash to using women’s bodies for political ends. The attention and protest towards Trump’s presidency within the US and across the world has brought attention to the issue of reproductive rights to new audiences. Social media platforms such as Twitter and old media platforms such as the magazine Teen Vogue have helped galvanise younger women in North America and Europe to become aware of the issue of reproductive rights.Footnote 31 Women’s marches have brought women from across generations together to focus on issues of reproduction, sexual harassment, and laws that curtail women’s autonomy over their bodies. It is leading women to confront the legacy of reproductive rights in their own states, such as the forced sterilisation programmes of African American women in North Carolina in the 1960s.Footnote 32 Of significant note was the referendum held in May 2018 in the Republic of Ireland to repeal the 8th Amendment of the Irish constitution: the vote to repeal the 8th ends a near total ban on abortion in the country. The significance of the referendum was felt not only in the Republic of Ireland but has led to growing pressure on Northern Ireland to change its abortion laws. While it would be a stretch to say such factors will overturn the global norm of restricting women’s access to reproductive health, the normative discourse in favour of reproductive rights is gaining momentum and funding from activists, philanthropists, and governments, suggesting the potential for backlash on a policy that was accepted in the past. Such a backlash is important not just within the US, but to elevate women’s access to reproductive rights as a global concern.
Concern 2: PEPFAR and global health’s US dependency problem
One of the main concerns linked to the global gag rule is how it will impact on the US government’s flagship project the President’s Emergency Plan for AIDS Relief (PEPFAR). PEPFAR was launched by President George W. Bush in 2003 to combat HIV/AIDS through a rapid deployment of funds to address prevention and treatment. PEPFAR has provided anti-retroviral treatment to 11 million people around the world; voluntary testing and counselling to 74 million people, support for 6.2 million orphans and vulnerable children, and provided prevention of mother-to-child transmission services to the end that 2 million babies have been born HIV-free under the programme.Footnote 33 Sixty-three countries receive bilateral funds from PEPFAR, with the programme having wider impact through multilateral financing programmes such as the Global Fund to fight HIV/AIDS, Tuberculosis and Malaria.Footnote 34 President Bush initially pledged US $15 billion, but to date the total funds enacted between 2004–17 amounts to US $75 million.Footnote 35 The reach and impact of PEPFAR should not be under-estimated. It is not without controversy (see below), however, PEPFAR has been a game-changer for the HIV/AIDS response; particularly with reference to the mass scaling up of provision of anti-retroviral treatment, and the wider impetus it provided for further action and funding towards combating the disease.Footnote 36
It is the impact, reach, and scale of PEPFAR that makes Trump such a concern for global health practitioners and policymakers, and HIV/AIDS activists. The major concern is that if Trump cuts funding to the programme this would be catastrophic for the HIV/AIDS treatment and response. Funding for HIV/AIDS has been in decline in recent years and there is a lack of available donors who would fill the gap left by the US government. There have been protracted efforts on willingness to pay for middle-income countries receiving PEPFAR funding; however, this has led to a stand-off between US agencies wanting recipient governments to fund more themselves and both donor and recipient agents knowing there is a common concern that any funding shortfalls would reverse any progress made.Footnote 37 Hence, should Trump cut PEPFAR, recipient states will not necessarily be able or willing to finance the shortfall in funds for HIV/AIDS provision, and despite new multilateral investment structures such as the Global Fund, there is no other actor that could fill the PEPFAR gap. The (relatively) minor concern is that while PEPFAR may remain for now, the global gag rule will impact on the services provided and funding streams of service providers in receipt of PEPFAR funds. Such providers will have to make difficult decisions as to either changing the services they provide or seeking funds from elsewhere.
Prior to Trump’s financial and ideological threats on PEPFAR, the origins of PEPFAR were problematic especially in progressing rights-based treatment programmes. Under the Bush presidency the primary prevention package emphasised the ‘ABC’ – abstinence, be faithful, and consistent use of condoms. The result was a public information campaign that it did not engage with the social and economic barriers faced by those most at risk of HIV infection. The Obama administration sought to promote a more encompassing prevention programme under PEPFAR, but in ideologically and religiously conservative recipient countries, the difficulties remain immense. As UNAIDS reported, young adults – particularly young women – lack the agency and autonomy over their bodies necessary to make decisions such as the use of condoms, refusal of sex, even choice of partner.Footnote 38 The risk to such a major flagship programme is thus twofold – funding cuts under a new administration and the revival of ideological intrusion into the prevention packages that suit evangelical and conservative fervour in some recipient countries.
Health gains are as vulnerable as global health financing is to any change in US politics. Global health has become dependent on US financing from flagship programmes such as PEPFAR for HIV/AIDS, multilateral financing of organisations such as the WHO, UNICEF and the World Bank, and non-state financing that comes from philanthropists such as the Bill and Melinda Gates Foundation and the Carter Centre. It is this dependency that poses the greater risk for global health governance and the lives that depend on US global health engagement: Trump did not create this risk but the wider uncertainty around his presidency exacerbates the sense of uncertainty and fragility.
Concern 3: Pandemic panic and global health security
The final concern is the security dilemma Trump poses to pandemic preparedness and response. In the global health context, we understand the security dilemma to mean that balance between doing ‘more harm than good’ in adopting security-oriented approaches to infectious disease risks.Footnote 39 Trump poses a twofold risk because he has not demonstrated much interest in a human-security centred approach to disease outbreak response, and he is defunding the research and health system strengthening programmes necessary to achieve global health security.
Initial evidence of this relates to funding for key actors that are directly involved in the preventative based approaches to global health security. Trump’s first proposed ‘skinny budget’ America First: A Budget Blueprint to Make America Great Again suggested cuts to domestic public health agencies such as the Food and Drug Administration (FDA), Health and Human Services, the Environment Protection Agency, the National Institute of Health (NIH), and global health agencies such as the Centers for Disease Control and Prevention (CDC) and USAID.Footnote 40 The proposed budget cuts to the National Health Institute were estimated to be around 20 per cent resulting in its lowest budget since 1999, and the CDC cuts would mean it was operating at its lowest budget in twenty years.Footnote 41 Part of the justification for such cuts was to reallocate US $54 billion of money to the US military and defence spending.Footnote 42 For some, such as the ex-Director of the CDC Tom Frieden, this is a dangerous divestment given the growing risk and commitment to global health security, tweeting ‘Proposed CDC budget: unsafe at any level of enactment. Would increase illness, death, risks to Americans, and health care costs.’Footnote 43 These cuts illustrate a lack of recognition of the role the research and science knowledge economy plays in both the wider economy of the US with regard to jobs, universities, the clinical and pharmaceutical private sector, and the provision of global health security.
Trump’s cuts to health agencies to invest in military procurement show a disinterest and misunderstanding of the role of the health-research in the US at best. At worse, it shows a disregard for the hard-won research gains that have linked research and investment to improve health outcomes – including securing global health against the threat of emerging and existing infectious diseases. These were battles being fought in the 1990s, when securitisation of infectious disease was at its bioterror peak. Trump’s cuts to health and science research budgets demonstrate three ongoing vulnerabilities within the global health security approach. First, it remains far too easy to displace the right to health and well-beingFootnote 44 with national security arguments. Second, there is disregard of how health-research feeds into the US economy and shapes the wider global knowledge economy. Finally, individual health insecurity feeds into the continuum of health insecurity at the state level. A limited understanding of security that does not fully take into account the risks and challenges of global health security and the role of key agencies such as the CDC in preventing pandemic outbreaks. At least two of these factors – the economy and security – are stated areas of importance for Trump. Recognising the importance of investment in health and science, Congress rejected Trump’s proposal and instead the Senate Appropriations Committee approved a bipartisan bill that proposed a US $2 billion increase to the budget of the National Institute of Health to applause from the committee audience.Footnote 45
Prior to his presidency, Trump used the Ebola and Zika outbreaks to push for tighter immigration and border controls for US health workers returning from affected states, tweeting ‘KEEP THEM OUT OF HERE!’ and that they ‘must suffer the consequences if they help’.Footnote 46 This cue suggests that Trump’s reaction will invoke the classic securitised response. The state, not individuals, must be secured through quarantining US borders and imposing harsh travel sanctions.
Under Obama’s presidency, the US (unusually) adopted a proactive global health security agenda that promoted health system strengthening as well as the usual specific research and treatment programmes for infectious diseases. The US played a key role in the H1N1 pandemic flu, the Ebola outbreak, and Zika-microcephaly outbreak. Barack Obama advocated coordinated leadership in global health at the highest political level: the US introduced the UN Security Council resolution to address the Ebola outbreak, and established the US $1 billion US Global Health Security Agenda (GHSA).Footnote 47 In Obama’s final years, the WHO adopted a new Health Emergencies Programme that was to provide logistic and political support in a timely manner to any emerging outbreak. This legacy means that when the WHO declares an outbreak a Public Health Emergency of International Concern (PHEIC), US funds and expertise will remain a significant contribution to curtailing such an outbreak. The concern is that Trump’s tone, to date, suggests a reactive, isolated approach. Should Trump follow a similar pattern to his position on Ebola and Zika – discriminatory tweets, heightening the language of risk and threat, targeting individuals and migrant populations – affected individuals insecurity will be exacerbated and compromise containment approaches.
Trump’s potential mishandling of an outbreak would not make him an anomaly within global health governance. The problem is that his behaviour to date suggests he entrenches rather than challenges the pattern of failure. In spite of the US-led engagement under President Obama, the two biggest outbreaks of the last five years – Ebola and Zika – were replete with lessons learned and failings in the wider system of global health governance. The response to the 2014–15 Ebola outbreak in Guinea, Liberia, and Sierra Leone has been criticised for WHO delays in calling the outbreak a PHEIC, the fuddled UN response, the risk-aversion of some military actors, gender blindness, lack of health system investment, NGO withdrawal, and a lack of government leadership and health ministry ineffectiveness in countries such as Guinea and Sierra Leone.Footnote 48 The extent of such criticism has led to numerous ‘lessons learned’ processes and reports by the institutions involved and the creation of the WHO’s Health Emergencies Programme.Footnote 49 Zika, following on from Ebola in 2016, may have been declared a PHEIC by the WHO in a timely manner, but the outbreak exposed similar problems of global health governance: weak infrastructure and health systems, gender blindness, reliance on free community volunteers and militaries as responders of last resort, and a disregard for the living conditions of poor women and their dependent families.Footnote 50
The lessons learned from the Ebola and Zika outbreaks must now, however, be applied under a Trump administration. In contrast to the Obama administration, the GHSA under the Trump administration may promote an understanding of ‘health threats’ consistent with Trump’s ‘traditional’ existential threat security lens: health risks are those that immediately threaten United States borders. This lens may lead to narrow defensive and harmful engagements, but also harm the furtive attempts made in recent years to progress global health governance from reaction to prevention. Under the GHSA, through specific programmes such as polio vaccine and outbreak tracing, tuberculosis treatment programmes, and linking maternal health to malarial programmes, the GHSA sought to find a balance between US Congress preference for high-profile, quick-impact vertical disease programming with longer term (less easy to trace) health systems strengthening.Footnote 51 Of course, the same problems continued – donor investment rarely matches disease burden (that is, maternal mortality programmes always run a poor second or third to infectious diseases prevention programmes) and the programmes themselves are not investments in health system strengthening.Footnote 52 Specifically, a Trump administration understanding of health as an immediate threat (that requires containment and defence orientated postures) risks the delicate gains attempted to date in trying to match vertical programmes to horizontal health system delivery. US-funded programme leaders are not going to risk trying to find funding and capacity to do both when facing political opposition and the threat of funding cuts.
The concern surrounding Trump and the global health security dilemma he poses is thus not an anomaly, but part of a wider problem of how global health responds to pandemic outbreaks – a focus on reaction and containment, rather than prevention. The response of President Trump to a disease outbreak is an unknown risk, however, given global health’s track record on effective disease outbreak control and management, to focus solely on Trump deflects attention from the wider systemic issues of delivering on global health security. Should another pandemic outbreak occur and Trump responds as predicted above, it would be a distraction and thus a mistake to focus solely on the role of his presidency in the provision of global health security. The focus instead should be on the efficacy of mechanisms that exist to deliver global health security through pandemic preparedness, and the wider drivers of how pandemic outbreaks come about through weak health systems and structural inequalities that limit and condition how people do or do not access health care. Trump should not be a convenient totem in which to project the insecurities and weaknesses that exist in the governance of global health security or a distraction to the barriers and enablers of such weaknesses. Instead, a rejection of his position and policies should and could serve to strengthen an equitable programme for global health governance.
Conclusion
Donald J. Trump has become a displacement activity in which global health governance can assign existing inequalities, ineffectiveness, and health security dilemmas to his presidency. Trump’s presidency certainly has the potential to significantly exacerbate problems in reproductive health, health financing, health research and global health security, and in some instances create new problems for global health governance. However, other than the reinstatement and extension of the Mexico City policy and attempts to cut global health investment, the impact of Trump’s presidency on global health is yet to be seen. Trump in the main has shown little interest or regard for global health, yet global health has shown interest in Trump. This interest is unsurprising given the significant impact the US has upon global health financing and research. What is surprising is how Trump is seen as somewhat of an outlier in global health when he in many ways aligns to existing norms of curtailing women’s access to reproductive health and a lack of understanding at best or disinterest at worse of world leaders towards global health security. President Obama was unique for his interest and his engagement in global health; it was certainly outside of the norm among the P5 leadership in the UN Security Council. Assigning fear and risk to Trump’s presidency has become a displacement activity for global health to not have to confront problems endemic to its governance. The long neglect of maternal mortality and reproductive rights, the competition and inequality in vertical ‘versus’ horizontal health system funding, a research and development system geared to drug and vaccine development that favours wealthier economies and their ailments. Instead of using Trump as a displacement activity, his presidency could be an opportunity to confront dependency on US financing model, the lack of a human-security centred definition of global health security, and the norm of restricting reproductive health. It is such engagement and confrontation with these issues that could see Trump’s presidency as being a catalyst for change rather than displacement as a means of preserving the uncomfortable status quo in global health.
