BURLINGTON, Vt. — Responding to the COVID-19 pandemic is expected to be a defining focus of U.S. President-elect Joe Biden’s approach to global health, development, and humanitarian engagement.
While some features of the incoming administration’s international pandemic plans are clear — particularly those that serve as direct rebukes to President Donald Trump — there are still a number of open questions about how Biden’s White House will marshal resources, organize the U.S. government, and shape global health assistance for a world transformed by COVID-19.
Biden’s COVID-19 plan commits to reversing Trump’s effort to withdraw from the World Health Organization and to reestablishing a National Security Council directorate for global health security and biodefense, which Trump eliminated.
It also pledges to elevate the Global Health Security Agenda, an initiative launched in 2014 to monitor and improve pandemic preparedness around the world, and commits to creating a Global Health Emergency Board to bring together world leaders and health experts in the event of any future declaration of a public health emergency of international concern by WHO.
Biden has not officially committed to joining the COVAX initiative for global vaccine distribution, but his team has reportedly met with those leading the effort.
One of the biggest open questions, which is outside of the incoming administration’s direct control but will have significant implications for the scale and ambition of its global response, is funding.
“We should really give additional funding space to the World Bank to scale up its support in low-income countries. … That's going to matter for health more than almost anything else that we could do.”— Amanda Glassman, executive vice president and senior fellow, Center for Global Development
The global portion of Biden’s plan for COVID-19 response includes directing the U.S. Agency for International Development, in coordination with other departments and agencies, to mobilize an international response. In the absence of new money — from a COVID-19 relief package, for example — that could be difficult.
USAID shut down its own COVID-19 task force earlier this year, in part because the agency already exhausted the money Congress appropriated in previous emergency funding bills for international response. Another package is currently under fierce negotiation, but with infections surging in the United States, economic pressure mounting, and lawmakers focused on delivering a massive vaccination rollout next year, experts expect it will remain challenging for global concerns to break through.
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“In that environment, trying to make the case for very deliberate, sustained high-level engagement on global health security is going to be complicated,” said Stephen Morrison, senior vice president and director of the Global Health Policy Center at the Center for Strategic and International Studies.
“It's going to be highly charged. It's going to require a strategy, and it's going to require high-level support. This is not something that's going to be conducted as a matter of diplomacy and internal wrangling at mid or lower levels of the administration. It's going to have to be tied directly to benefiting the domestic [response]. It's going to have to build off of the logic of what is being done domestically. It has to be deeply integrated into the domestic strategy,” he said.
Those competing pressures in the United States will likely collide with a dire financial picture in many low- and middle-income countries, which threatens to derail some of the assumptions that have undergirded U.S. global health engagement in recent years, according to Amanda Glassman, executive vice president and senior fellow at the Center for Global Development.
The global health community in the U.S. has “not come to terms” with the “scale of the fiscal crisis in low- and middle-income countries,” Glassman said, but it poses a direct challenge to core narratives about shifting toward shared responsibility for financing global health programs and eventually transitioning countries away from aid.
“The timelines on that have all changed, and that means more resource requirements. One question is whether the will is there in the U.S. Congress and the administration to increase global health allocations,” Glassman said.
With that uncertainty over U.S. resources in mind, one of the Biden administration’s biggest priorities on the global health front should be marshaling support for the World Bank and regional development banks to play as big a role as possible in financing COVID-19 response, Glassman said.
“We should really give additional funding space to the World Bank to scale up its support in low-income countries, because I think that's going to matter for health more than almost anything else that we could do,” she said.
Unless something unexpected happens in the final weeks of the Trump administration, Biden’s White House is likely to inherit some questions about how the U.S. government ought to be organized to address the international aspects of the pandemic.
In May, details emerged about a proposal from the Department of State to create a new, centralized initiative for global pandemic response, modeled off the U.S. President’s Emergency Plan for AIDS Relief. That proposal was matched by congressional bills that would establish similar initiatives, but which some experts said included stronger “guardrails” to preserve USAID’s independence and leadership on global health programs.
It is unclear whether the Biden administration will look to move forward with any of those options, and some of the president-elect’s choices for his transition team suggest a State Department-led pandemic initiative is unlikely.
One of those appointments is Jeremy Konyndyk, who served as USAID’s disaster response chief during the Barack Obama administration. He emerged as an early public critic of Trump’s COVID-19 response and is now a volunteer member of Biden’s agency review teams for both the Department of State and the Department of Health and Human Services.
Some news reports have suggested Konyndyk, currently a senior fellow at the Center for Global Development, is among the names under consideration to lead USAID, underlining the possibility that the Biden administration could look to someone with humanitarian and outbreak response credentials.
“I would look very closely at what Jeremy Konyndyk has said,” said Conor Savoy, executive director of the Modernizing Foreign Assistance Network.
While Konyndyk declined to comment on current discussions, his most detailed comments came in June testimony to the Senate Foreign Relations Committee, where he gave recommendations for organizing the government to mount a global pandemic response.
“I do not believe that modeling the new initiatives on PEPFAR, as some of these proposals envision, is the best approach,” he told the committee, citing potential problems with interagency conflict, the State Department’s “weak institutional track record on global health,” and the need for strong coordination from the White House.
Instead, Konyndyk argued for a “lighter structure” based around decentralized coordination, with the State Department leading on “a surge in global diplomatic outreach.”
The U.S. needs to be engaging at a high level through the G-7 group of major industrial nations, G-20 group of industrial and emerging-market nations, United Nations Security Council, and mechanisms such as the ACT Accelerator, Morrison said. He noted that global leadership will also require moving away from confrontation with China to find areas for collaboration.
Any U.S. strategy also needs to address the economic impacts of COVID-19, debt and fiscal challenges, and worsening humanitarian crises and rising poverty, Morrison said.
“Global diplomacy on these matters has been woeful,” he said.
Regardless of the specific direction it takes on pandemic response, the incoming administration will have to contend with a global health security landscape that has become politicized in unprecedented ways since the start of the COVID-19 crisis, Morrison said.
The new team will need to build support on Capitol Hill for a “logical and coherent approach,” particularly when it comes to U.S. involvement in reforms at WHO, which has taken the brunt of the Trump administration’s rejection of global cooperation.
Morrison is looking for the Biden team to designate leadership on the international front as an early signal of the shape its engagement will take.
“I think we'll see some appointments made on a sort of urgent basis,” he said. “The leadership on the international side has to be seen as one of those things that is part of the package of must-dos in this next phase.”
Adva Saldinger, in Washington, contributed to this article.