A box of plain white trucker hats labelled “MAKE HEALTH SECURITY GREAT AGAIN” sits on the floor of our offices at HSP, a playful nod to Trump’s ridiculous yet bold campaign slogan. This was a perfect punch line among staff when he first announced his presidential campaign last June—until he became the “presumptive” Republican nominee. No one is laughing anymore. Reality has set in: Donald Trump may become the next president of the United States. We hid the hats. Someday they might be funny again (probably not), but as a non-profit working at the nexus of health, security, development, and diplomacy, this is serious business. What will the future of health security look like under the current candidates’ presidencies? Will building capacity to prevent, detect, and respond to infectious disease outbreaks that can rapidly cripple the globe be a priority? What about antimicrobial resistance, which has the potential to kill millions each year if left unchecked? And what about funding?
Raising policymakers’ awareness to the importance of health security issues on a global scale has not been an easy road. Obama’s Global Health Security Agenda (GHSA), launched in February 2014, is a true milestone in uniting the ideals of global health, national security, and sustainable development toward a world more safe and secure from potential biological threats. As a policy framework, it makes sense, providing a platform for the global community to harmonize efforts and work towards shared objectives. Of course, when launched, there was no new money behind it. Coincidentally, in March 2014, Guinea reported the first cases of Ebola in the most recent outbreak. It took this devastating, widespread outbreak to fuel momentum and funding behind the Agenda in the U.S. with an emergency supplemental from Congressto bolster the global efforts of the CDC and USAID in particular. While the U.S. media hype of Ebola has leveled (though theaftermath is widespread and continues), Zika has further pressed the conversation, forcing policymakers to recognize that infectious diseases continue to be a clear and present national security threat requiring active stewardship.
There is undeniably an ebb and flow to policy actions addressing global health security, typically following occasional wake up calls from Mother Nature (e.g. Ebola and Zika) or a nefarious lone actor in the case of Amerithrax. The strides made on biodefense after 9/11 and pandemic influenza threats under former President George W. Bush and his Homeland Security Council certainly deserve significant credit. The Obama administration made further progress to unite the global health and national security communities—first with the National Strategy for Countering Biological Threats and later with the first Quadrennial Diplomacy and Development Review (QDDR). The QDDR set the stage for other major initiatives, including Feed the Future and the Global Health Initiative, designed to make measured progress on root causes of global poverty and instability, such as violent extremism, gender disparity, and educational attainment. These programs emphasize health systems strengthening over stove piped capacity-building for a single disease, which is ultimately the necessary approach to improve global health security.
More recently, the Obama administration released the GHSA to catalyze progress toward the lagging International Health Regulations (IHR) commitments. It is seemingly awkwardly but intentionally set to sunset in 2019 to ensure investment and progress continues into the next administration. While its current utility has been buoyed by recent outbreaks, the GHSA’s fate as an “agenda” is less than clear. While there is room to debate what a future GHSA should look like, the core ideals and principles it has helped highlight to policymakers should certainly remain a priority regardless of the new administration. So, let’s speculate on the likelihood of the current presidential front-runners carrying on the torch of global health security. Our research team (i.e. a smart graduate student) outlines the key data points here. You make the call.
At a March 2016 town hall event, army veteran Robert Kitelinger asked Trump what, in his opinion, are the top three functions of the U.S. government? Trump responded, “well, the greatest function of all, by far, is security for our nation, I would also say health care, I would also say education. I mean, there are many, many things, but I would say the top three are security, security, security.” From this answer alone, there is no denying that Trump is focused on national security. In nearly every other mention Trump has made about national security, we found a particular focus on protecting the U.S. from immigrants, whom he views as a security threat. “Thousands and thousands of people are infiltrating our country. We don’t know who they are.” Building a wall between the U.S. and Mexico, creating the strongest military the U.S. has ever had, and ending what he calls the “theft” of American jobs are talking points throughout Trump’s speeches which support his view of the U.S. as the center of the world. Even when Trump describes U.S. foreign action in countries such as Iraq, Syria, and Afghanistan, these statements are centered on American interests. Generously translated, Trump appears to take the notion that if the U.S. is strong at home, the world is a safer place. Fair enough.
Trump’s speeches are laden with the words “health” and “health care”, but only with reference to the U.S. health system (i.e. nothing on global health). “Total catastrophe” and “the big lie” are just a taste of the harsh language used to describe his view on Obamacare. For months, Trump promised a new health care plan far superior to Obamacare, yet the recent release of his plan has faced harsh criticism, with one critic claiming the plan resembles “the efforts of a foreign student trying to learn health policy as a second language.” Trump has a public, firm view on the future of U.S. public health, but his plans make no mention of U.S. involvement in health on a global scale. With reference to health security, Donald Trump has yet to combine “health” and “security” to discuss the interplay of these two overarching concepts.
Foreign policy and public diplomacy are undoubtedly critical components to U.S. national security. However, Trump’s record here is monotonous, emphasizing foreign policy only with relation to U.S. military intervention and defense in what he calls an “America First” foreign policy. Trump believes that U.S. foreign policy has been a disaster for decades, citing the Cold War as the last big win for U.S. foreign engagement. This stanch view on extreme military strength and U.S.-centric attitude have been consistent principles in Trump’s view of U.S. foreign policy for decades. In a 1990 interview with Playboy, when asked about a Trump presidency, he commented in third person saying, “he would believe very strongly in extreme military strength. He wouldn’t trust anyone. He wouldn’t trust the Russians; he wouldn’t trust our allies; he’d have a huge military arsenal, perfect it, understand it.” Although many aspects of the beliefs Trump expressed in this interview have changed over the years, such as his statement “I don’t want to be president. I’m one hundred percent sure” and his conviction that if he did run, he’d be best suited as a Democrat, Trump’s single-minded view of foreign policy has proven to withstand the tests of time.
Trump’s recent foreign policy speech on April 27th made no mention of public diplomacy, reflecting his long-withstanding policy positions that have made no reference to global health or diplomacy, let alone to the importance of scientific evidence in policymaking. How would Trump, as a leader, advocate for major health security policy actions such as international vaccine campaigns when he actively promotes the myth that vaccines cause autism on Twitter? Bottom line: Trump is a wild card when it comes to health and diplomacy.
Does this mean that a vote for Trump as president is a vote for de-emphasis on international health and diplomacy as essential national security pillars? Not necessarily. Again, being generous, Trump has no background in any of these areas or in policymaking itself; he has not had to make decisions about the nation’s health or security and thus has not yet experienced the reality or gravity of these policy issues. So far, his priorities have focused on campaign marketing over policy development, which in some ways has been wildly successful. We have hats with a play on his slogan in our office. That’s success.
From helping to create the DOJ Violence Against Women office during her time as First Lady to leading the development of the first QDDR in 2010 while Secretary of State, few policymakers rival Hillary Clinton’s depth of experience. Her background covers an expansive repertoire of issues, including positions, policies, and actions directly linked to addressing health security issues on both a national and global scale. As First Lady, Clinton was an active supporter of USAID; then-Administrator Brian Atwood stated that Clinton “deserves more credit than anyone” for helping to secure congressional funding for USAID in the late 1990s. Clinton herself reaffirmed her long-standing support for USAID when, two days into her role as Secretary of State, she addressed USAID at their headquarters stating, “As First Lady… I was able to see the work you do, and to see the results with my own eyes, and to travel a lot of miles to support you and your predecessors in the important work of literally embodying American values…So I’m ready to roll up my sleeves and get to work with you.” During her time at State, Clinton’s focus was to strengthen collaboration between USAID and State, using the QDDR as a framework to reevaluate the priorities, organization, and resource allocation of each agency. With this track record, we can safely assume that a Hillary Clinton presidency would come with a priority for health and diplomacy policies and programs.
Throughout her career, Clinton has been active and vocal about speaking on behalf of women worldwide, pushing forequal access to health care, employment, education, and legal recourse for all. Forging truly global alliances for closing the gender gap, eradicating disease, and countering violent extremism were all top priorities during her tenure as Secretary of State. Clinton also has a track record to back her vision to better connect development investments with national security. In a 2010 speech, Clinton stated, “what we will do is leverage the expertise of our diplomats and military on behalf of development, and vice versa. The three Ds [defense, diplomacy, development] must be mutually reinforcing.” Likewise, Clinton’s current campaign website clearly articulates her priority for foreign affairs is to strengthen existing partnerships and foster new ones.
Taken together, Clinton’s history points to the likelihood that, in office, she will maintain, if not boost, the level of support and funding for global health security issues. Throughout her career, she has been forced to make tough policy decisions, often changing her position entirely. This characteristic that has drawn criticism to her current candidacy, but is a realistic occurrence for any veteran policymaker. Regardless of that, Clinton has a consistent vision for health, security, and diplomacy, backed by real experience making the sort of policy decisions that most will never face. Will she actually follow through if she gets to the Oval Office? As scientists who are driven by data over conjecture, we think she likely will. Only time will tell.
While Sanders is likely not going to make it through a potentially contested convention, we certainly respect and feel the ‘Bern’, so we did our homework on him as well. With regard to his work toward improving global health security, Sanders leaves us with virtually nothing to reference. He has taken a clear view on domestic public health through a continued push for a single-payer, universal health care system. Aside from a few “yes” votes on foreign aid-related issues during his time in the Senate, Sanders does not have much to show for work on international health. His foreign policy remarks do not mention global health and describe diplomacy only in terms of preventing international conflict and war. As a contemporary Robin Hood looking to provide free higher education, universal health care, higher wages, and more jobs, we applaud his idealism but know there is no free lunch: the funding will need to come from somewhere. Based on our research, there will have to be cuts, and themes of global health security are nowhere to be found as a priority in Sander’s campaign. One could surmise that in order to fund his priority big-ticket items such as education and health care, resources for GHSA and other programs that address health security won’t be sustained.
The future of U.S. policy and programs toward global health security lies in the hands of one of these three, final presidential candidates. Our research reinforced what we already knew of the two presumptive candidates; Trump has little to no record while Clinton has the best understanding of, and would likely strongly support, the underlying themes of the Global Health Security Agenda and other efforts to enhance health security. President Clinton would no doubt build upon her work as Secretary of State to further counter terrorism while enhancing support for public diplomacy, global health, and development. President Trump would likely only support the GHSA if West Africa paid for it. Indeed, if we wake up to a President Trump on November 9th, stop by the HSP office for your free hat. There will be much work to (re)do.
About the Authors
Kate Consavage is a Program Associate at HSP. She holds a B.S. in Biology from Emmanuel College, and she currently attends Georgetown University in pursuit of a M.S. in Global Health.
Jason Rao, PhD is a former senior policy advisor to President Obama and current Advisory Board Chair at HSP. He teaches global health security and diplomacy at Georgetown and Cornell Universities.