Global Health Security in the Trump Era: Time to Worry?

Is it time to ring the alarm bell on a declining US commitment to global health security? For most of the past year, I would have said no. But after the last few weeks, I’m starting to think so. And the simultaneous news of a new Ebola outbreak in the Democratic Republic of Congo underscores the stakes at play here.

The Trump administration came in talking a good game on global health security, and during the president’s first year in office it appeared that this would be one of the few areas of policy continuity between the Trump and Obama administrations. Then-Secretary of Health and Human Services Tom Price told the World Health Assembly last May that the US is committed to a “cooperative, transparent, and effective international response to outbreaks of infectious disease.” At the Global Health Security Agenda ministerial meeting last fall in Uganda, the United States affirmed its intention to back the initiative for another five years, to 2024. This spring the White House put out a strong, encouraging statement about the importance of US health security investments around the world. And new HHS Secretary Alex Azar chose to focus his World Health Day editorial this spring on the importance of pandemic preparedness.

But actions speak louder than op-eds. And we have recently seen an alarming set of developments that point toward a serious erosion of US health security preparedness.

The first was the administration’s failure to seek renewed funding to sustain CDC and USAID’s post-Ebola investments in infectious disease preparedness overseas. It is far cheaper and easier to contain infectious disease threats at the source, rather than waiting for them to reach US soil. The lack of basic systems to prevent, detect, and respond to outbreaks in Guinea, Sierra Leone, and Liberia were what allowed the Ebola outbreak to explode there. New CDC and USAID investments, initiated with funding from the Ebola emergency funding package, have worked to rectify this in 49 at-risk countries around the world. Yet this work is set to be phased out in 39 of those countries, after the administration declined to seek Congressional funding to sustain the investments. These budget choices stand in stark contrast to the administration’s other rhetoric on the Global Health Security Agenda (GHSA), and suggest a serious internal disconnect between policy and budget priorities. And as my colleagues here at CGD noted a few days ago, financing for this kind of health security preparedness was inadequate even before the administration began shuttering these programs.

Then last week the administration announced more bad budget news: its rescission proposal to Congress seeks to return $252 million in residual Ebola emergency response funds from the 2014-15 outbreak. That outbreak is now over, so why is returning this unspent money so problematic? Because this move, too, ignores an important lesson of the Ebola experience: the fact that outbreaks do not respect the government’s budget cycle.

I know this particular chunk of money quite well—I managed it when I led USAID’s Ebola response operation. The fact that the crisis happened to hit at the end of a fiscal year, when both CDC and USAID’s budgets were largely tapped out, delayed and distorted the initial response. This ultimately cost more in both money and lives, because outbreak control costs grow dramatically the longer you wait to respond. With Ebola we missed the window for early containment (funding was not the only factor—but an important one) and so ultimately the US government was forced to appropriate more than $5 billion to end the outbreak and invest in preparedness against future health crises. The lack of USAID and CDC funding also distorted the response by creating huge pressure to use the Department of Defense for missions it was not well suited to implement—based mainly on the fact that the Department had resources and better-suited agencies didn’t.

After the crisis ended, the leadership of USAID and the White House Office of Management and Budget informally agreed to leave a chunk of unspent money on USAID’s books as a rainy-day fund for future disease crises. While the money had been appropriated for Ebola, the 2015 Appropriations Act contained a provision allowing the funds to be redirected if the government deemed another international disease event to be “severe, sustained, and spreading.” The Obama administration successfully road-tested this authority during the Zika outbreak, reprogramming other Ebola funds to combat that disease.

Congress then worked with the administration last year to establish a formal fund toward this purpose—but only appropriated $70 million into it, and another $35 million in 2018. Combined with the residual $252 million, these amounts constitute a reasonably robust reserve fund. But if Congress accepts the administration’s proposal to strip out the $252 million, what’s left would amount to only about two-thirds of what the government spent on the early Ebola ramp-up period.

The last concerning development is the departure of key health security champions from the administration. It remains to be seen whether Secretary Azar will make GHSA a major priority of his tenure, as Secretary Price seemed poised to do. Tom Bossert, the White House’s well-regarded homeland security chief and a strong supporter of biosecurity preparedness within the White House, was an early casualty of John Bolton’s NSC leadership reshuffles. And just last week news broke that NSC biosecurity chief Rear Admiral Tim Ziemer would be leaving the NSC as well. His position is being eliminated and his team dissolved across existing NSC directorates on Weapons of Mass Destruction and International Organizations and Alliances.

Ziemer’s departure and the accompanying elimination of the biosecurity directorate may sound like a minor bureaucratic change. But it is actually deeply concerning: another major lesson of Ebola is that combating infectious disease takes a whole-of-government effort—and getting that right takes dedicated, focused, experienced White House coordination and leadership. When Ebola first arose in West Africa, there was no single home in the White House or the interagency charged with pulling together all components of a US response. It took months of interagency wrangling and the appointment of an “Ebola czar” to pull the international and domestic components into place. Breaking up the only NSC directorate with specialized knowledge of infectious disease crises means the White House will be slower off its marks when the next big disease threat emerges.

Taken together, these developments point toward an abandonment of US global investments in health security preparedness; a reduction in resources available for future outbreak response; and a dissolution of the White House’s capabilities to effectively manage either of those things. Having lived through the searing experience of managing an outbreak for which we were unprepared, I find it incredible that anyone would voluntarily unlearn the hard-won lessons of that experience. But that is what appears to be happening. And America is less safe for it.