I first encountered President Trump's now infamous Twitter account in 2014, when the future president offered his two cents on the Ebola epidemic. The virus had inevitably found its way into a hospital on the outskirts of Dallas, forty miles south of my hometown; American healthcare workers infected with Ebola on the ground in Guinea and Sierra Leone were being brought back for treatment at the Center for Disease Control in Atlanta and the the National Institutes of Health outside of our nation's capital. Public uproar reached fever pitch, and Trump chose, of course, to further fuel the hysteria. "The US cannot allow EBOLA infected people back," he tweeted. "People that go to far away places to help out are great—but must suffer the consequences!"
At the time, Trump's words struck me as obtuse, dangerous, and dehumanizing. I could sense his fear. Trump's "EBOLA" was foreign and incurable, perhaps even apocalyptic. His reality did not allow for Ebola to be a complex but manageable disease of global health, challenged by ill-equipped hospitals and cultural miscommunication.
Global health—public and private sector initiatives around health issues that transcend national borders, like climate change, obesity, flash pandemics, and antibiotic resistance—rarely surfaced during the presidential campaign. And it shouldn't have: Global health policy for the United States has remained remarkably stable since the end of the Second World War. Presidents in both parties have historically perceived it as a cost-effective investment for forging positive diplomatic ties, ensuring global security, and fulfilling a moral imperative to help others in need.
It was FDR who brought America into the United Nations, which later gave birth to the World Health Organization, and Kennedy who presided over the creation of the United States Agency for International Development (USAID) and the Peace Corps. Clinton funded AIDS research while in office, and later created a foundation to negotiate lower drug prices for the same disease. George W. Bush perhaps had the most significant impact of all, passing both the President's Emergency Plan for AIDS Relief (PEPFAR) and the President's Malaria Initiative (PMI). Both programs, expanded under the Obama presidency, provisioned treatment for millions in Africa suffering from HIV/AIDS and malaria.
The United States is one of the world's largest funders of global health activity today. Millions around the world, in virtually every corner of the globe, depend on the US for food, water, research funding, and technical expertise to beat back problems in human health. I was reminded of this last year when I attended a speech, given at my graduate school, by Anote Tong, the former president of Kiribati. He shared the plight of his island country in the Pacific Ocean, and how the ancestral lands of its one hundred thousand residents will be swallowed by rising tides within the next decade. Facing the inevitable, his country is training their population with vocational skills so that they can migrate as net economic contributors, rather than as climate refugees. Their plan relies on collaboration with USAID to better manage their resources and minimize health risks from communicable diseases, buying them time to train their constituents and safely migrate them out of the country. Without USAID, their plan would simply fall apart.
But to many, perhaps including Trump, global health may seem like globalization gone too far; dominated by faraway international institutions and out-of-touch elites, funneling taxpayer money towards causes across oceans unknown to American middle-class families. Unlike in the UK and France, or Italy and Austria, this Trumpian brand of anti-globalization involves a unique denial of scientific consensus—and poses a special threat to global health and its future.
It is Trump's "America First" worldview alongside his distortion of science that leads me, as a medical student with a background in this field, to believe that his administration will methodically assault global health in the coming years. My diagnosis isn't made lightly. Already Trump is taking his destructive behavior to three global-health fronts.
He's normalizing pseudoscience
On the first front, Trump is calling into question the truth behind climate change, the effectiveness of vaccines, and the facts behind evidence-based medicine. His words may irreversibly shift the Overton window on science, to the point of threatening programs like vaccine campaigns responsible for eradicating diseases such as polio in recent years. In the political backrooms of the new West Wing, a number of his appointees have already signaled an interest in eliminating federal funding for biomedical research, potentially prompting an unheralded era of academic work biased by corporate interests, and subsequently misguided global health policy. When sound research does materialize on challenges like cancer or obesity, Trump may unpredictably reject logic and gravitate towards conspiracy theories instead, using anecdotes like his McDonald's hankering to explain away relationships connecting fast food consumption to diabetes and heart attacks. Even worse, he may dismiss it as fake news.
He's alienating institutions
Simultaneously, Trump has worked to dismantle or withdraw our country from the international institutions facilitating efforts in global health. He has repeatedly berated the UN, predicted that the European Union will soon crumble, and wavered on adhering to the Paris Climate Agreement passed last year, which has massive implications for human health. Even five years ago, he accused the World Bank of wrongdoing when its analysts tied poverty to climate change. And on the campaign trail, Trump threatened to withdraw America from the World Trade Organization, where nations come together to draft international law on access to generic drugs and medical devices. All of these organizations and accords have vital roles to play in global health, and backing away from them would suggest to the world that the United States is giving up its seat at the table.
He doesn't believe in foreign aid
On the third front, Trump has incessantly attacked foreign aid. While railing against globalization, Trump made it a campaign issue, promising to hold hostage important aid dollars designated for fighting disease and strengthening health systems. Before taking office, his aides reportedly had the audacity to ask the State Department if Bush's PEPFAR was really an international entitlement program. And members of his own party are already catching his drift. Last month, Lindsey Graham and Ted Cruz introduced a bill in the Senate calling for the United States to defund the UN in retaliation against the recent Security Council resolution on Israeli settlements. Taking a step further, Mike Rogers introduced a bill in the House of Representatives earlier this year calling for the United States to terminate its relationships with the UN altogether.
These efforts, paired with Trump's penchant for erratic and unilateral action, pose an unprecedented threat the world order our country helped create only seventy years ago—the same one has made stunning progress in lifting so many out of poverty, increasing life expectancies, and innovating new approaches to treat humanity's oldest diseases. Destroying the architecture of global health would be in neither America's, nor the world's interest. Few other areas of our policy can directly affect the wellbeing of millions living on our planet, keep our borders secure, and shape our country's image around the globe so profoundly.
In the long term, America's withdrawal from global health threatens to lead to a greater decline in its prestige and stature on the world stage. It may serve as a prelude of what's to come, in a world where emerging countries like China and India, corporations like Pfizer and Merck, and foundations chaired by the global elite, like Bill Gates, Mark Zuckerberg, and, yes, even the Clintons, chart a course for our planet.
Two years ago, when Ebola was rapidly spreading throughout West Africa, it was the US Army's 101st Airborne Division that led an effective operation to halt its progress. The operation itself was not unusual, and followed a long American military tradition of providing humanitarian assistance in the wake of natural and biological disasters. Their actions were bold, compassionate, and economically sensible—like most of America's work in global health since the days of FDR.
I can only imagine what 140-character message our new president will tweet at the start of the next pandemic.