As international efforts to counter worldwide health challenges that include antimicrobial resistance and infectious disease surveillance began to gather force at the end of 2016, a transition in U.S. global health leadership was underway — from a president who ushered in the “Global Health Initiative” (it fizzled out) and the Global Health Security Agenda (off to a strong start), whose administration overturned the ban on travelers who live with HIV entering the U.S, and oversaw a more than tripling of the numbers of people world wide receiving antiretroviral treatment for HIV, to a new president whose global health interests had yet to be seen. The newly elected president had promised to “put America first,” but what that change would mean to U.S. leadership of global health responses — that do, indeed, protect American interests and security at home and abroad — as well as to international commitments and global health partnerships remained unknown at the start of the new year. Answers, and more questions have come as the year unfolded.
In the week after President Trump’s inauguration, global HIV research and response advocates who had urged the new administration to maintain the momentum of work at the National Institutes of Health and PEPFAR welcomed the news that the president had asked National Institutes of Health head Francis Collins and U.S. Global AIDS Coordinator Ambassador Deborah Birx to remain in their posts. That week as well, however, the President signed an executive order restoring the “Mexico City Policy,” restricting funds from overseas family planning programs that provided information or services to terminate pregnancies. The restriction, also known as the “Global Gag Rule,” had been rescinded and restored under different administrations since first signed into effect by President Reagan – but the policy that President Trump signed into effect was greatly expanded — applying to all overseas health programs — including those providing HIV services to prevent mother to child transmission of the virus.
The Conference on Retroviruses and Opportunistic Infections opened with a renunciation of an executive order signed by President Trump two weeks earlier barring people from seven Muslim majority countries from entering the United States. “CROI is a truly international gathering,” CROI conference chair Dr. Susan Buchbinder said as she welcomed more than 4000 delegates, about 40 percent of whom came here from outside the United States. The ban, which been halted by a federal judge, would have kept scientists from attending the conference and participating in the exchange of knowledge, Dr. Buchbinder noted. “If policies like this are not swiftly and definitively rejected,” she said, “they will have a detrimental effect on science.”
The third month of the Trump administration brought new indications of the president’s priorities, with the release of a White House budget plan outline proposing to cut nearly a fifth of the budget for the National Institutes of Health and slash funding for the Department of State and USAID. The plan also proposed eliminating the NIH Fogarty International Center — a funding and coordinating entity for international health research and training. At the same time the plan announced the intention of preserving “sufficient resources to maintain current commitments and all current patient levels on HIV/AIDS treatment under the President’s Emergency Plan for AIDS Relief,” although with greatly diminished USAID and State Department funding what that would meant remained unclear.
Spurred in part by the White House budget outline with its proposed cuts to biomedical as well as environmental research and programs, science supporters took calls for investments in research and evidence-based policies to streets around the world in about 600 events from the rain-soaked National Mall in Washington D.C., to cities across the United States and around the world, on the streets of Cape Town, Kampala, Lagos, Accra, Mexico City, Munich, Rio and Rome, and cities across Canada, Australia, New Zealand and Japan.
With overseas exposure that began with a volunteer stint in Kenya, a term on the House Foreign Affairs Committee, and continuing work in global health and governance arenas, former Congressman and former U.S. Ambassador to Tanzania Mark Andrew Green was President Trump’s nominee for USAID administrator. In contrast to White House budget proposals, Green had voiced strong support for foreign aid funding, and the cost-effectiveness of the outcomes from those investments, including by saying “Africa is also our focus because that’s where American businesses want to be.” In May also, though, the White House released details of the expanded Mexico City Policy, now titled “Protecting Life in Global Health Assistance,”and restricting international support for a broad array of medical services and disease responses that include HIV prevention and treatment, maternal and child health interventions, malaria care and control, Zika monitoring, surveillance, diagnosis, and more — with an estimated impact of $8.8 billion in U.S. funding for global health responses.
June brought hope for global health spending when, in budget hearings fellow Republicans rejected President Trump’s proposed cuts to foreign aid that would eliminate nearly a third of the current State Department budget, including a billion dollar cut to PEPFAR as “radical and reckless ” (Sen. Lindsay Graham, R-SC) and “a complete waste of time” (Sen. Bob Corker,R-TN). At a hearing examining the impacts of the White House proposed cut of $7.2 billion from National Institutes of Health — more than 20 percent of its current budget — setting the world’s leading research centers back to levels not seen in 15 years, Sen. Roy Blunt (R-MO), remarked “It’s hard to imagine we would do that,” while Sen. Lamar Alexander (R-TN) explained: “My goal is not to decrease funding [for medical research] but to continue to increase it.” Concerning to global infectious disease response advocates, however, was a glimpse of White House plans for PEPFAR with U.S. Secretary of State Rex Tillerson’s description of a strategy to: “sustain the HIV/AIDS treatments in 11 countries to continue to take those to conclusion. As patients roll off those rolls, new treatments can be available.” In the absence of a cure for HIV, the only way for a patient to “take treatment to conclusion,” or “roll off the rolls” of treatment that offers patients a normal, or near normal life expectancy, is to die.
With a $1.1 billion increase in funding for the National Institutes of Health as well as an NIH budget that includes $73 million for the Fogarty International Center, and continued funding for the U.S. President’s Emergency Plan for AIDS Relief at current levels, the two House funding subcommittees with jurisdiction over most global and domestic health programs posted bills in mid-July which maintained funding trends over recent years and rejected the most devastating cuts to global infectious disease responses and research proposed by the Trump administration. At the same time the release of a White House “Major Savings and Reforms” document outlined limits to how funding, while sustained, would also be constrained, describing a plan within the proposed budget for PEPFAR, to “prioritize 12 countries in which the United States will continue to work towards epidemic control, while maintaining all current PEPFAR-supported patient levels on treatment across the program,” and concluding: “This proposal would allow PEPFAR to continue to achieve impact within a lower budget by reprioritizing resources and leveraging funding from other donors and host country governments.” A modelling study presented by the London School of Hygiene and Tropical Medicine at the International AIDS Conference in Paris later that month, though, indicated that while under the White House plan the numbers of people on treatment would remain the same, as new infections occurred the percentage of people with suppressed viruses would steadily decline. The number of people becoming infected with HIV would climb steeply each year, with, by 2030, the year currently targeted to end HIV as a global health threat instead seeing 2 million new infections. The numbers of people losing their lives to HIV, having dropped steeply, would level off, and nearly 300,000 people would die as a result of the treatable disease each year.
With Congress on recess, August was a quiet month for policy, but studies released that month highlighted the impact of funding decisions legislators would eventually make. A study published in The Lancet produced the first estimates of the role of tuberculosis in the deaths of children under five years old, indicating that of about 239,000 children under the age of 15 who died of tuberculosis in 2015, about 80 percent of them — about 191,000 — were children under five years old, that about 17 percent of them were children with HIV, and about 96 percent of all of the children died without receiving treatment for the disease, with indications that most of these children went undiagnosed as well. That month also a study published in Open Forum Infectious Diseases found evidence of Ebola in the semen of 11 of 137 Ebola survivors who donated samples more than two years after the onset of their illness. The findings posed a challenge, researchers noted, to integrate accurate messages about risks of sexual transmission into community education, without adding to burdens of stigma and isolation already experienced by survivors of the virus.
In mid-September a State Department “Strategy for Accelerating HIV/AIDS Epidemic Control (2017-2020)” raised the number of “focus countries” once again — to 13 — and described those countries as ones with high HIV prevalence, but also with “the potential to achieve HIV/AIDS epidemic control by 2020 . . .” The document also revealed that the “focus” countries would be Botswana, Côte d’Ivoire, Haiti, Kenya, Lesotho, Malawi, Namibia, Rwanda, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe, but didn’t describe what would happen in those countries, and at what cost to other efforts.
At the mid-October infectious disease focused IDWeek in San Diego, National Institute of Allergy and Infectious Diseases head Dr. Anthony Fauci recounted 33 years of visits to Capitol Hill to testify before Congress, “every time in association with an emerging infectious disease.” The first was HIV, then a single dot on a map of Africa, representing a potential global health threat. The dots cover the map, obscuring national and continental outlines now, he noted, with lessons, and responses accruing with each, including through the Global Health Security Agenda to build disease prevention, detection, surveillance and control capacities in countries around the world, CEPI, the Coalition for Epidemic Preparedness Innovations, a partnership of public, private, philanthropic and civil society entities to advance vaccine development, and continuing NIH efforts prioritizing pathogens for which new medicines are needed. All will require sustained funding, he said, even as more needs await. “Emerging infectious diseases have been with us forever,” he said. “They are with us now, and they will always be with us.”
With funding for the Global Health Security Agenda as well as funding allocated in response to Ebola, and since directed to filling health system gaps to enable future responses set to run out in 2019, the nonprofit PATH released an analysis arguing that continued United States leadership of investments and actions to build health capacities worldwide is critical to national as well as global interests. The analysis laid out a series of strategic and investment recommendations to maximize the impact of U.S. global health security leadership. In addition to continued strong support of the GHSA, they include the provision of dedicated and reliable funding for global health security efforts at the U.S. Centers for Disease Control and Prevention, USAID, the Department of Defense, and the Department of State, the establishment of emergency reserve funds at those agencies, the maintenance of strong support for the U.S. President’s Emergency Plan for AIDS Relief and other U.S. led programs that contribute to medical and laboratory capacity building, and sustained, predictable support for research and development both towards expanded knowledge of pathogens with pandemic potential and measures against them.
And, here we are. The tax reform package passed this week, projected to add at least $1.4 trillion to the national deficit over the next ten years has raised concerns among global and domestic health advocates, providers, and consumers who note the deficit will increase pressure to reduce further discretionary federal spending on health programs, and, unless Congress overrides current law requiring automatic spending cuts to offset significant increases to the deficit, will trigger automatic cuts to all programs.
Stay tuned. Science Speaks will be home for the holidays for the rest of the year. We’ll be back in January.