June 14, 2024

Two decades ago, the United States led the establishment of a new global public health order that began with the fight against a devastating HIV epidemic in Africa. The initiative’s success solidified America’s role as the world’s biggest funder of global health programs and the most influential actor in coordinating global efforts to combat infectious diseases. Though the American-led push to fight AIDS does not draw much domestic attention, it is perhaps the single-most impactful US government program ever, saving 25 million lives over the past 20 years.

Global health is necessarily an exercise in long-term thinking. Investments can take decades to pay off. The Covid-19 pandemic infused a fresh urgency into these efforts — but it also politicized public health to a degree not seen in decades. Now, the global health community is trying to forge a new consensus while facing novel obstacles to international cooperation.

2024 will be a pivotal year for that effort, one in which the future of international efforts to address global health threats and improve medical care in the developing world will be decided.

The year begins ignominiously: Several provisions of the President’s Emergency Plan for AIDS Relief, or PEPFAR, the signature program of the fight against AIDS that intensified during the early 2000s, have now expired after Congress failed to pass a reauthorization bill last fall due to objections from House Republicans. Over the years, the program has covered antiviral treatments for more than 20 million people, and it has prevented 5.5 million babies from being born with HIV by providing care to stop mother-to-child transmission.

The impasse over that program, which was started under former President George W. Bush, a Republican, and enjoyed bipartisan support for years, was “a pretty strong signal that we’re in danger of losing — even more than we have already — the bipartisan support for US leadership in the global health sphere,” said Elisha Dunn-Georgiou, president and CEO of the Global Health Council, a US-based nonprofit that represents a variety of health advocacy groups.

It is a warning that the United States’ commitment to global health is slipping. But PEPFAR is just the beginning — the commitment of America and its peer countries to participating in and funding multilateral global health initiatives will be tested repeatedly this year.

In the spring, representatives from most of the world’s nations will meet to finalize (or not) an international treaty to prevent and better prepare for future pandemics. This summer, major nongovernmental organizations responsible for financing health programs across the developing world will begin making their cases for the next round of funding from wealthy states, many of which have seen the rise of nationalist political movements that are resistant to international collaboration.

And in November, the US presidential election could usher in a second Trump administration that would be much less willing to engage with global health efforts than the US has been historically. The fate of billions of dollars in aid will be at stake, as will America’s role as a leader in international health diplomacy.

“This is a year where countries are going to be having a conversation about their relationship to other countries and peoples in the world,” said Chris Collins, president and CEO of Friends of the Global Fight Against AIDS, Tuberculosis and Malaria. “The Covid crisis is abating. We need to see whether we’re going to learn its lessons.”

The future of global health cooperation suddenly appears more doubtful

If you were to pick a starting point for the modern era of global health, the launch of PEPFAR in 2003 would be as good a candidate as any.

At the turn of the century, more than 2 million people were dying of AIDS in sub-Saharan Africa every year, yet international aid was paltry. President Bush marshaled congressional and international support for a dramatic expansion of testing, treatment, and prevention programs. Two decades and $110 billion in spending later, the program has saved an estimated 25 million lives.

For years, PEPFAR continued to enjoy bipartisan backing. A 2018 bill to reauthorize the program for another five years passed by unanimous consent in the Senate and a voice vote in the House — an indication of how uncontroversial support for global HIV programs remained up to that point.

President Bush speaks at a microphone while Jean William “Bill” Pape, “Aunt” Manyongo Mosima “Kuene” Tantoh, and Bishop Paul Yowakim look on.

President George W. Bush speaks on the President’s Emergency Plan for AIDS Relief (PEPFAR) in the Rose Garden of the White House in 2007.
Brooks Kraft LLC/Corbis via Getty Images

But last year, as the clock ticked down on a September 30 deadline when the previous reauthorization would lapse, Congress found itself stuck. House Republicans, few of whom were in office when the initiative launched m20 years ago, demanded concessions on abortion-related provisions in exchange for agreeing to reauthorize the program. Anti-abortion activists had raised concerns about PEPFAR, citing the Biden administration’s work on sexual and reproductive health in other global health programs. But PEPFAR itself had already clarified in a 2022 document that it “does not fund abortions,” and Democrats refused to agree to the GOP’s demands that they add new abortion restrictions to the program’s funding. On October 1, several of PEPFAR’s provisions expired.

In practice, the initial impact of that lapse has been limited. Most of PEPFAR’S funding is mandatory, meaning that it has already been appropriated by Congress. The provisions that expired last year focus instead on how the funds are used, requiring, for example, that a certain percentage of PEPFAR funding be spent on treatment and that another share be set aside for orphans.

Global health advocates are still hoping Congress will attach PEPFAR reauthorization to an omnibus bill this year. They place symbolic significance on the US reaffirming its commitment to the AIDS fight in Africa and global health in general.

“We still want to see PEPFAR [reauthorization] happen, symbolically as much practically,” Jenny Ottenhoff, senior policy director at the ONE Campaign, told me.

That’s because the American government remains the single-most important entity in global health. The US spent nearly $13 billion on global health programs in its 2023 fiscal year. It provides one-third of the funding to and has a permanent seat on the board of the Global Fund to Fight AIDS, Tuberculosis and Malaria, an organization also started during the George W. Bush administration, which supports prevention and treatment for some of the world’s most deadly diseases in 130 countries.

The US iso the single largest contributor to the World Bank’s newly established Pandemic Fund. And along with the United Kingdom and the Bill and Melinda Gates Foundation, the United States underwrites much of the budget for Gavi, the Vaccine Alliance, which largely supports vaccine programs in developing countries and has contributed to the vaccination of nearly 1 billion children since its founding in 2000.

But the failure to reauthorize PEPFAR signals growing ambivalence among some US political leaders about funding health programs around the world. The internationalist “compassionate conservatives” of yesteryear, perhaps best embodied in George W. Bush’s presidency, have been pushed out of the Republican Party, replaced by Trump acolytes less interested in public health domestically or abroad. Donald Trump’s “America First” nationalism and the ferocious conservative backlash against public health authorities during Covid have unmoored a field that long viewed itself as above politics.

“The whole pandemic experience, the Trump experience … have altered the landscape. I don’t think we can go back,” said Jen Kates, director of global health and HIV policy at the health policy think tank KFF.

The divisions wrought by the pandemic could complicate what should be a landmark moment for the global health community: the World Health Assembly in Geneva in May, where representatives from around the world hope to agree to a pandemic treaty that would set up a new system for coordinated disease monitoring and the development of vaccines and treatment in a future public health emergency.

Negotiations have been ongoing for months, but the sides remain divided. A recent Politico Europe report, citing unnamed diplomats, cast doubt on whether any agreement can be reached and portrayed the talks as calcified. Developed countries, including the US, desire more unfettered access to data and surveillance in developing countries. The US has also been arguing behind closed doors that the enforcement language should be softened. Developing nations, on the other hand, want more assurances about their access to medical countermeasures in a future health emergency, after struggling to obtain vaccines during Covid.

The talks turn on sensitive questions of intellectual property rights, with the US caught between its role as the leader in international health diplomacy and the parochial interests of US for-profit companies that do not want their products commandeered without what they consider adequate compensation. These thorny issues, largely set aside during the rush to stem AIDS in Africa decades ago but made impossible to ignore by Covid-19, have unsettled the longstanding global health consensus.

Even four years into the pandemic, with at least 7 million dead worldwide and counting, the world’s nations may not be able to agree on a substantive plan to avert such a catastrophe in the future. A watered-down treaty, or a failure to reach an agreement at all, would be a stinging failure.

How much will the world put up for global health programs?

That failure could undermine the next round of contributions to some of the world’s largest funders of global health activities. The Global Fund to Fight AIDS, Tuberculosis and Malaria and Gavi, the Vaccine Alliance — two major sources of international health aid — are both entering a new fundraising cycle this summer, with final commitments to be made in 2025.

Both organizations saw onetime boosts in contributions during the first two years of the Covid-19 pandemic. But advocates fear that enthusiasm has dissipated and there may be an appreciable drop-off in the next round of funding.

“That is going to be the next canary in the coal mine for where global health is heading,” Ottenhoff said.

The Global Fund has approved more than $66 billion in funding since its inception in 2002 and the programs it supports have saved an estimated 59 million lives in the past two decades. Gavi, meanwhile, funds vaccination programs in developing countries, with a particular emphasis on children. Since its founding in 2000, it has distributed more than $18 billion in funding and played a critical role in Covax, the international Covid-19 vaccine distribution initiative.

A person receives a vaccine shot in a room full of masked people.

A Covid-19 vaccine clinic in Jakarta, Indonesia, which was supported by the COVAX initiative.
Dimas Ardian/Bloomberg via Getty Images

Both programs were remarkably successful in their last replenishment rounds, bolstered by the immediacy of the ongoing Covid-19 crisis. In 2020, Gavi received $8.8 billion, an all-time high, for its 2021–2025 cycle. Two years later, the Global Fund secured a record-setting $15.7 billion in commitments through 2025. Having weathered the Trump presidency, during which the White House proposed (but Congress ultimately rejected) cuts to the US’s contributions to these funds, the prospects for future global health investment had brightened.

But a few years later, as the Global Fund and Gavi prepare to solicit donors again, they are facing headwinds. A weak global economy has left many countries with fewer dollars to spare and empowered nationalist political movements that are skeptical of international aid. And there are new competitors for a limited pool of resources, such as the World Bank’s Pandemic Fund, established in 2022.

“You have all these folks with their hands out, and there’s only so much money,” said Rebecca Katz, director of the Center for Global Health Science and Security at Georgetown University.

The limits of state-based capital have global health leaders advocating for overhauling the rules for nongovernment institutions, such as multilateral development banks, that could unlock more health financing for developing countries. Some of those reforms will be considered at the World Bank’s spring meeting, another inflection point in the year’s global health agenda.

The big questions behind a pivotal year in global health

Global health is in a transitional period. The age of PEPFAR is past, figuratively if not literally, and the world is moving on from the Covid-19 public health emergency.

Advocates are beginning to reimagine how best to achieve their goals. For years, the focus, especially in the US, has been on pumping as much money as possible into countries in need, with an emphasis on specific health crises, like HIV and malaria. Covid-19, however, laid bare the need to strengthen health systems in a more general way so they can be more resilient in the face of the next emergency. That may require more work to build institutions in developing nations that will last and that can sustain themselves.

But it is ultimately the world’s governments that set the rules and hold the purse strings for most global health activities. That makes this year’s record-breaking number of elections, culminating with the US presidential contest in November, the other fulcrum on which the future of those efforts will turn.

Congress may have previously overruled Trump’s attempts to cut global health funding, but in a second term, he could find a more pliant Capitol Hill if Republicans hold the House and take the Senate.

There would be no obvious replacement — in terms of sheer financial resources or diplomatic heft — if the United States were to withdraw further from international health efforts. The outcomes of elections in the UK and elsewhere could lead other longtime supporters of global health to pull back, too.

“If the US were to pull back money, I think it would be very unlikely for other countries to fill that gap,” Kates told me. “The inability to raise more money, to agree on things, the lack of PEPFAR reauthorization … creates confusion on the ground. People in the field start to lose confidence in what’s available to them.”

The global health community finds itself in a position it has not been in for decades: unable to take government support as a given. Advocates are fighting the tide of nationalism in an attempt to preserve and reshape an international multilateral movement that has led to impressive gains in this century.

The opportunities for continued progress are evident. New malaria vaccines are rolling out to target a disease that still kills half a million people in Africa every year. Africa is also in the midst of establishing a new public health order, modeled on ideals of self-governance and self-reliance that many experts believe must be the future of global health.

But the risk of backsliding is palpable. Public opinion polls show that most Americans continue to support US leadership in global health. But it’s the votes they cast in November that will dictate the country’s future engagement with global health initiatives.

And due to the US’s outsize role in setting the global health agenda, the consequences will be felt all over the world.

“If we were to step back from our leadership in global health,” Collins said, “epidemics we are winning against would resurge.”

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