Auxiliary nurse Claudia Guillermo administers a measles vaccination to 1-year-old Jimena Nicole Xoj Caal at a UNICEF-supported health centre in the city of Cobán. | CREDIT: © UNICEF / NYHQ2012-2216 / SUSAN MARKISZA Global Health Agenda for the Biden Administration Mark Leon Goldberg December 14, 2020 By: Mark Leon Goldberg on December 14, 2020 The COVID-19 pandemic has made global health a top tier issue in Washington. In today’s episode we explore what opportunities might exist for the incoming Biden administration and Congress to advance a global health agenda premised on strengthening international cooperation to take on common health challenges Loyce Pace is President and CEO of the Global Health Council. We kick off discussing how the Trump administration’s approach to global health was something of departure from typical bi-partisan support for health and development around the world before discussing in depth how a Biden administration and new Congress may advance a global health agenda, including what a global response to COVID-19 might look like. Get the podcast to listen later Apple Podcasts | Google Podcasts | Spotify | Stitcher | Radio Public Today’s episode is produced in partnership with the Better World Campaign as part of a series examining the opportunities for strengthening multilateral engagement by the new Biden-Harris administration and the incoming 117th Congress. To learn more and access additional episodes in this series, please visit http://getusback.org/ Transcript Loyce Pace [00:02:16] A lot of people, when they look at or think about the Trump administration’s approach to global health- I would say, that’s been largely independent, perhaps, really somewhat removed and is certainly different from what we’ve seen previously with the U.S.- that so many people have commented on the fact that they’ve grown to expect the U.S. would be at the table, if not at the head of the table, for a number of these discussions, particularly when it comes to something like the global response or international response to a pandemic. And yet, as we’ve seen with Covid, that hasn’t been the case, right? And that absence is pretty striking and unsettling for people, not just this year but in the forums leading up to 2020. In some ways, or in many ways rather, Covid-19 has put a finer point on that. And yeah, I think we’ll probably see something pretty different from the Biden administration come 2021. Mark Leon Goldberg [00:03:21] It seems to me, as I said having reported on these issues for many years, that global health is one of those areas that historically or typically had broad bipartisan buy-in and consensus. I mean, I started reporting on these things in the George W. Bush era and the PEPFAR, the signature USAID’s policy its called the President’s Emergency Plan for AIDS Relief and that “P” stood for President George W. Bush. Of course, some of the things that they emphasized were a little different between administrations, but there had been, at least until now, a degree of consistency. Loyce Pace [00:04:00] And I think the good news, Mark, is there’s still bipartisanship, to be clear. Because in Congress, you’ve had them year after year, for example, protect the global health budget and the broader global development budget. Each time the Trump administration came with its proposal to cut those funds, Congress, on a bipartisan basis, decided to go against what the president requested and retain those resources. And so I think that’s good. It’s a good sign of the fortitude of global health and development and the fact that even now, in a highly political environment that we have in the U.S., global health seems to have weathered the storm somehow on the Hill. [00:04:42] We still get caught up in the wake of things. A great example of that is the back and forth around emergency funding for Covid-19. And we’re finding that ordinarily when we’d be able to have funding, international funding specifically, for the global response to be part of that. That’s been harder to do just because it has been harder for them to come to a decision overall about that funding. And so then we get caught up in that back and forth. But with regards to regular appropriations and even some legislation, even when it comes to WHO honestly, we’ve still been able to hold the line to a great degree on the Hill. And I think that really matters because we want any incoming administration to be able to lean on Congress for that support. And I think the good news is we don’t need to worry as much about rebuilding that from the ground up for a Biden-Harris team. How Can the US Congress Support Global Health Diplomacy Mark Leon Goldberg [00:05:44] So before we get on to opportunities for the incoming administration, what are you looking towards in Congress? Since you just mentioned Congress, which, you know, we’re speaking at this moment in which Democrats have retained control of the House, we don’t know what’s going to happen in the Senate just yet. But as you said, these are generally bipartisan issues, historically at least. What are you looking towards in the Congress to signal to you what might come next or what opportunities might exist for the United States to reassert its leadership on global health issues? Loyce Pace [00:06:21] I think first and foremost, we will want to still see some level of global funding in any relief bill. Again, we don’t know where that’s going to land, given our ongoing politics here. But I think that would send a really strong signal if this Congress or the next, for that matter, would be able and willing to pass a bill that would address pretty urgent needs at home and abroad. I think that’s number one. Mark Leon Goldberg [00:06:53] Can I just stop you there? Do you have a do you have like a ballpark estimate or suggested amount for international Covid relief to be included? Loyce Pace [00:07:04] I sure do, as any good advocate would. We have been pushing lately for 20 billion dollars and that sounds like a lot until you look at the entire package where that fits commiserate with how global health and development sit in the overall U.S. budget. It’s really what we might see as a drop in the bucket when it comes to the need, especially when we think about how much the response or the pandemic itself has wrought this past year. But our argument is -well, first off, that’s inclusive of health and development, to be clear. And there’s a good chunk of that that would go towards multilateral organizations like Global Fund and Gavi who are supporting the COVAX and ACT-Accelerator. So for people in the audience who might not know what those things are, essentially they’re international collaboratives that have been stood up by collaborating agencies, including WHO and those that I’ve just mentioned, to come together around the global response and specifically around technologies like tests and diagnostics, as well as vaccines and other innovations that would be helpful, particularly to low and middle-income countries in their response to Covid-19. So that’s been a really important effort. Mark Leon Goldberg [00:08:28] The ACT, I believe stands for the Access to Tools Accelerator. And the tools in question are those things that would help countries deal with covid, whether it’s treatments or in the case of Covax, the vaccine or therapeutic things like that. And it’s this international WHO-backed collaborative. So you’re saying some of that chunk of that 20 billion ought to go there? Loyce Pace [00:08:48] Yes, exactly. And then we think it’s critically important not to forget the range of global health issues that have been left behind, essentially due to the pandemic. You have people who aren’t getting their TB meds or antiretroviral therapies because you don’t have access to those health facilities or health workers in the same way. Similarly, we’re falling behind on some maternal and child health metrics because of the limitations of those programs now, given stay-at-home orders or supply chain delays, or other issues. And all of that requires funding. And then you have reports coming out and that came out earlier this year, for example, around the cost of immunization. You have health workers and frontline professionals trying to keep up with this need while also addressing Covid in these countries. But of course, they need PPE and other special needs, that wasn’t required this time last year, to deliver vaccines to kids, for example. So if we’re going to continue with this work, it is going to cost a bit more money and if only to repurpose or restructure some of those programs as they’ve been designed to date. And so there is some funding in our request that really accounts for the full spectrum of global health needs, not only a global health emergency, like a pandemic. Mark Leon Goldberg [00:10:12] So beyond Congress, you’ve mentioned certain issues around how the incoming administration may engage on Covid issues internationally. I mean, how might the fact of this pandemic help catalyze a return to U.S. global health leadership after you have this incredible move by the Trump administration to withdraw from the World Health Organization in the midst of a pandemic. Is there sort of an equal and opposite opportunity for the incoming Biden administration to engage in a way that it might not have engaged if not for the fact that there is this pandemic? Loyce Paice [00:10:58] Yeah, absolutely. And actually, I would call it an enhanced and opposite opportunity, right? Mark Leon Goldberg [00:11:03] An instant opposite opportunity. There you go. Loyce Pace [00:11:04] I think ideally we’re not just coming back, but we’re coming back in a very different way. I think we’ve all learned a lot from this past year, both about our politics, about our personal lives and values, and a whole range of lessons. At least that’s my experience with 2020. And so, if I’m thinking politically, and about our policymakers, I think you’ve even heard the president-elect sort of hint at this. Of course, he has clearly committed to rescinding the decision to leave WHO and so that would no longer be on the table in a Biden administration. And I think that’s a relief to many of us who pushed back against that order or decision when it was handed down earlier this year. [00:11:50] But beyond that, I think your question is the right one. You know, it’s not just about coming back to the table, but really being mindful of what it looks like for us to reenter those halls and those discussions. And I hope that the U.S. would take an opportunity to step back and ask what went wrong and led us to a situation where we could walk away so easily? I think that is one question. Also, what happened while we were gone? Right? And maybe how were we missed is a question, but also what might have changed and worked differently and perhaps even better in our absence? In other words, does it make us sort of rethink ways that we can improve on the way that we engage, the way we even believe we’re leading? Mark Leon Goldberg [00:12:55] Can I ask you to answer that question? I mean, to what extent has the global health landscape and institutions like the WHO evolved or changed with this kind of recent U.S. withdrawal from the table? [00:13:09] Yeah, I think you had countries really looking up and saying, oh, wait, one of our friends isn’t here anymore. And it just happens to be one of our friends who often would take the lead with the pledge or otherwise convene the group of us around this particular issue. Certainly, it wasn’t always the U.S., but I think it’s fair to say that the U.S., -first of all, has been and still remains to some degree, a lead donor. RighT? But also would be the one to call to order or call people to action right around about a particular issue. And what has happened is other countries had to do that without us. And I think that was important for us all to experience to a great degree. Mark Leon Goldberg [00:14:01] What’s an example of that? An action of that happening over the last few years? Loyce Pace [00:14:04] I mean, look at WHO reform and discussions around that. This year, people were really questioning what WHO’s role should be. And I think our stance is -you saw this with the Trump administration- was we’re just not going to have any confidence in them. And in fact, we are going to disengage entirely. Whereby other countries, of the G-7 for example, said well, wait a minute. There are changes that should be made or there are things that we should consider, but we want to sit at the table with WHO or at least with each other, to determine what those changes or revisions could or should be. It was really striking, for example, at the World Health Assembly earlier this year, the sort of first-iteration of that, back in May, whereby you had all of these countries and even heads of state. Not only the health ministers, but you had these very strong commitments and statements that were made in support of WHO, recognizing the nature of this moment, this year. This was even just when we were partway through Covid-19. [00:15:08] But everyone was really showing up and saying, look, we know that it’s critically important that we stand with each other, that we stand with WHO, and that we all fight this thing together. And the U.S. was the only country that stood out and said, you know, we’re not happy. We blame this country. We blame this institution. And I get it. Every nation has its prerogative to get up and say whatever they choose. But it was quite striking that the US chose, at that moment, not to stand shoulder to shoulder with the rest of the world in its response. And I think a lot of us found that disappointing- Mark Leon Goldberg [00:15:46] It was weird. I saw that. You had President Xi give this magnanimous speech pledging vaccine support to Africa and all this. And then you had Alex Azar, the U.S. Health and Human Services Secretary, just give this petty and spiteful speech. Loyce Pace [00:16:02] And it wasn’t very diplomatic. Mark Leon Goldberg [00:16:05] It’s honestly like you’re watching a geopolitical shift in action. Loyce Pace [00:16:10] It was really strange. Yeah. It was really quite strange. Mark Leon Goldberg [00:16:13] So that actually leads me to to a set of questions I have for you on opportunities for vaccine diplomacy on the part of the Biden administration and what like elements of Covid vaccine diplomacy might be meaningful and also demonstrate that the U.S. is willing to once again work cooperatively in the race to manufacture and access vaccines? You saw this vaccine nationalism on one side and then vaccine multilateralism as embodied by institutions like Covax. What might an effective Biden administration vaccine diplomacy look like to you? Loyce Pace [00:16:54] I think it would mean a lot to join Covax. I think even just taking the step to call them up and say, okay, “we want to be a part of this community,” would be critically important. Already we make commitments to institutions like Gavi and Global Fund. And again, an ask that we have, is that we look towards enhancing or increasing those commitments so that funding could be used towards something like a Covax. And so I think that alone would be powerful. Both showing up with dollars, but also with the commitment of real leadership. [00:17:36] And then even just- I wouldn’t discount the power of an express commitment to fair and equitable vaccine delivery worldwide. Of course, the president-elect will be concerned about how he is ensuring that he keeps a commitment to the American people to address their very real needs, particularly among our at-risk populations. And yet, you have things like this executive order from this week from the Trump administration really doubling down on its America first policy. We had a similar stance around supplies like masks and ventilators and the like, earlier this year. And while it’s understandable that that level of fear and sense of scarcity and crisis, we know that none of us is really going to survive this or make it to the other side of Covid-19 unless we’re all protected, right? And if nothing else, to just see it as a factor of our own self-interest, it would make sense to step into that space internationally and again, work in cooperation with other countries to deliver vaccines to the people who need them. [00:18:59] And guess what? This can help the U.S. too, right? There is a reason why high-income countries have signed up to be part of this collaborative and it’s not only to do good in the world and to help other people elsewhere but also because they see a mutual benefit because we aren’t sure from whence the innovation will come. And it’s not just about vaccines, but also other really important innovations that come out of these shared resources. And so I think that will send a very strong signal if the Biden administration is willing and able to work in that way. Mark Leon Goldberg [00:19:37] Beyond Covid, what other opportunities do you see in the coming months for renewed U.S. engagement, specifically in multilateral platforms on global health issues? Are there any specific health issues you see ripe for the taking in terms of the U.S. grabbing the baton or any other opportunities for the U.S. to engage multilaterally on health issues? Loyce Pace [00:20:04] Goodness, there’s probably too much. But look, we still very much need to finish the fight in a number of areas. We still- We’re very close to to the finish line in Polio. We still have a very real fight with HIV, right? Let alone the other big three, if we think about the TB and Malaria triad with HIV. And so really doubling down on those commitments, I think presents an important opportunity for the U.S. because as you mentioned before, going back to PEPFAR, the President’s Emergency Plan for AIDS Relief, and given the establishment of the Global Fund around that same time, both largely spurred or led by the U.S. government. Then, we can really see through on these commitments and investments that we’ve made. We’ve poured a lot into these programs and we’ve seen the results of them, the fruits of our labor, if you will. And so it seems as though we would want to be a part of seeing that through. And so I see that as very ripe for us to return to the stage and express to the world that we’re still very much committed to immunizations and infectious disease and the kind of the fundamentals of global health, as we’ve come to know them over the past couple of decades. [00:21:22] I think another area, though, that’s going to be important for us is -especially given our historic investments- it’s going to be around primary health care. And you don’t hear the U.S. talk a lot about something like UHC or universal health coverage, obviously. But I think there’s going to at least be a higher level of understanding and recognition that health systems are critically important. And the fundamentals of public health are going to need to be in place in a very different way so that there is some resilience to whatever the next shock might be because I think now, we have to admit, that there could be another Covid, right? We don’t know what’s around the corner and many of us in the advocacy space have been saying this for a while. [00:22:10] Look, we’ve been lucky that things haven’t gotten to this point before now. And we were hopeful never to have something like what’s happened in 2020. But there have been other countries and regions of the world who have battled this right, who have battled Ebola, who have dealt with H1N1 and SARS and the like and not to mention Zika. And so this has been brewing for a while and I think we’ve been trying to make the case, that while specific investments have been incredibly powerful and important, we have to break through the silos and understand the importance of systemic investment as well. And so I think there’s a really big opportunity for the U.S. to align with countries like Germany who are really strong in this area. And really show up and say, OK, we get it. We might not be able to fund every health system around the world but we are going to approach this in a way that allows us to kind of lift all boats if you will, and really build this base on which these other priorities can stand those. Mark Leon Goldberg [00:23:23] That would be an interesting shift to see. The UN for the last few years, as you well know, has been championing UHC, universal health coverage. And it would be just interesting to see if the United States would get on board as more of a key partner in some of these efforts. Loyce Pace [00:23:40] Yeah, it would move a little bit, you know? And it could be as simple as -and this is hardly simple, right? -But even as an initial step, what does it look like for us to reconsider, assess voluntary contributions? Especially when it comes to WHO -coming back to your question of how we shift multilaterally- that might need to be in sync with whatever the member states decide around reform as an example. But I think this is something WHO has been seeking for a while and has recognized that they need and that could make them even stronger as an institution. And again, I think we watch these leaders, these professionals, to be able to shift or pivot as needed and truly address the root needs. And the only way they can do that, I think, is by us unlocking things a bit so that there’s a bit more flexibility. So that, I think that could be an interesting first step for the administration in the first year or so, for sure. Mark Leon Goldberg [00:24:44] There are a number of organizations and civil society groups in the United States and around the world. What opportunities exist now for the new administration to deal more proactively with them? Loyce Pace [00:24:59] Yeah, I like that question a lot because I think in all of this covid response chatter, which is again, critically important, we forget about civil society. And I think even in response to the crisis, a lot of the power players have kind of left us behind and forgotten about folks on the front lines. People living and working in communities who have really been critical to the response. And so, I think there’s a real opportunity to revisit some sort of renewed engagement with civil society actors. I’d really love to see that as part of any multilateral discussion, certainly but even outside of that- how the U.S. operates in the world, how we sort of flip the script to be even more locally-led. [00:25:45] Now, given how we’ve seen countries and regions do, in the correct response, and how they’ve demonstrated what it looks like to be working a decentralized model, these were assumptions I think people have made to say, well, you know, there has to be a lot of control for the mother ship with U.S. agencies and actors. And yet, we haven’t had the luxury of operating that way this year. And so I think it challenges us to rethink the model of international development and health broadly, but in particular, how the U.S. has approached it. Again, there’s been a lot of good done, but I think that we could do even better if we rethink our models and our ways of doing business. So I’m excited about that, too. Mark Leon Goldberg [00:26:28] Well, thank you so much, Loyce. This was great. Loyce Pace [00:26:30] Of course. Happy to be here, Mark.