The promise and pitfalls of an 'America First' global health strategy

It’s been a whirlwind year for global health. The U.S. government, which has served as the largest donor to the sector, sent tremors when it dismantled the U.S. Agency for International Development and terminated the majority of its programs. It then transitioned management of what was remaining to the State Department. The administration has also made significant cuts to the U.S. Centres for Disease Control and Prevention, put in motion the withdrawal of the U.S. from the World Health Organization, and cut funding to Gavi, the Vaccine Alliance, among other actions. With widespread layoffs and program shutdowns, the global health sector spent this year in limbo, wondering what role the United States may play moving forward. But then, in September, the State Department released its “America First” global health strategy, which outlines the Trump administration’s priorities. This includes a focus on direct contracts with partner countries, increased collaboration with faith-based organizations and the private sector, and a shift away from the traditional reliance on nongovernmental organizations. It also paves the way for partner countries to take greater ownership and pay for their own programs. In a Devex Pro Briefing, professor Lawrence Gostin, founding director of the O’Neill Institute for National and Global Health Law, and Rachel Bonnifield, director of the global health policy program at the Center for Global Development, unpacked the implications of this new strategy. In this discussion, the two experts explored issues such as the State Department’s capacity in actualizing this strategy; the administration’s bypassing of Congress; the stated aims of countering Chinese influence; criticism of NGOs; the role of multilateral institutions; the fate of family planning; the status of the U.S. President’s Plan for AIDS Relief in Africa; gaps in credibility for the administration; and the potential for integration of health services into national strategies as opposed to a siloed approach. “Is the Trump administration serious? Is there going to be funding behind it? Are they in it at least for a period of time that will assure stability in the transition?” Gostin asked. “All those questions are unknown, and there’s a lot of skepticism.” But there’s also a potential upside to this strategy, Bonnifield said. “There is some real vision in this strategy that could be disruptive in a good way. I think there are a lot of risks, and for a lot of reasons, it’s hard to trust what the execution of that vision will look like,” she said. “I would urge this community instead of being defensive about it — even though it’s hard, even though you have to swallow your ego to some extent — to try and find that positive vision and use our energy to push things as far as possible in that direction.”