1 month ago
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CLINICAL MATTERS
Within hours after his inauguration for a second term, US President Donald Trump signed a slew of executive orders aimed at reshaping the international policies of the United States. Included among these policy shifts were the withdrawal of the US from the World Health Organization (WHO), and the pausing of all foreign aid. These two decisions have the potential to cause a catastrophe because the United States has been a major player in shaping global health policies for a very long time. While most of us hope that these decisions will be modified or rescinded, they are causing a lot of anxiety for public health experts. There is a lot of uncertainty about whether important partnerships to improve health, such as those with PEPFAR and USAID, will continue.
The US was a founding member of the WHO, which was established in 1945 to achieve the highest possible level of health for all of the world’s people. Its functions include the control of epidemic and endemic diseases, training and teaching public health and medical treatment of disease, and the promotion and establishment of international standards for diagnostics and biological products. The WHO is responsible for the monitoring of potential disease outbreaks and declares a public health emergency of international concern when a new pandemic occurs. It also coordinates equitable delivery of lifesaving interventions such as what happened with vaccines sourced through the COVAX facility. The US has always been a major contributor to the global health programs of the WHO, and US physicians and scientists provide valuable technical assistance and policy guidance.
Unfortunately, during the Covid-19 pandemic, there were doubts cast on the WHO’s ability to investigate the origins of SARS-CoV-2 in China. These disputes fueled a lot of baseless conspiracy theories. This includes the alleged laboratory leak hypothesis which has been largely debunked by subsequent genomic analysis. Personally, I was not happy with the WHO’s undue focus on expensive and hard to use RT-PCR diagnostics early in the Covid-19 pandemic, especially for resource-limited settings. They should have instead emphasized tried and true public health measures such as quarantine and contact tracing. The WHO, however, did provide the Philippines with indispensable technical assistance and was able to bring in a significant number of Covid-19 vaccines through the COVAX facility. Overall, WHO has significantly contributed to our nation’s health, and I believe the US leaving the organization will have a disproportionate impact on the WHO’s ability to regulate global health concerns. The repercussions, including ultimately an effect on the health security of the US itself, may ripple on for many years.
The WHO’s ability to coordinate multi-country initiatives, such as the unprecedented genomic monitoring of SARS-CoV-2 variants, rapid evaluation of diagnostics, and the expedited clinical trials for different potential treatments for Covid-19 were very useful and benefited all countries, not just resource-constrained ones. The sharing of technical information facilitated by the WHO was essential in enabling countries to develop timely interventions that ended up saving millions of lives.
The executive order putting a pause to all foreign aid is wreaking havoc on US-funded global healthcare interventions. PEPFAR (Presidential Emergency Plan for AIDS Relief) which was established in 2003 by President George W. Bush, a Republican like President Trump, has provided critical funding for life-sustaining antiretroviral treatment as well as HIV prevention programs in Africa. To date, an estimated 26 million lives have been saved. The pause in funding has placed in jeopardy anti-retroviral treatment for over 20 million people, mostly in Africa. Even a short interruption will result in the emergence of HIV drug resistance, making it more difficult to treat people with HIV in the long run. It will also result in an increase in new HIV infections since antiretrovirals suppress viral replication which in turn decreases the risk of transmission.
In the Philippines, the Department of Health provides free antiretroviral treatment for Filipinos so ARVs will continue even without PEPFAR funding. However, our testing programs and PrEP (pre-exposure prophylaxis) programs, which both help to slow down the alarming increase in HIV cases locally, have already been adversely impacted. USAID, another long-time US-funded development partner, likewise contributes to the Global Fund which has HIV, malaria, and tuberculosis programs around the world. These programs are active in the Philippines, and many grant recipients are in limbo while the Global Fund reassesses the impact of the potential pull-out of US contributions.
All this is happening even as the possibility of a known anti-vaxxer becoming the Department of Human and Health Services looms. If that occurs, we expect more permanent cuts in funding for proven life-saving interventions and the research that enables finding these medicines.In addition, there is a risk that the money for these programs will shift to unproven and potentially dangerous pseudoscientific remedies. Many are hoping that the US Senate will exercise its oversight function wisely and that President Trump will field a more conventional candidate for this job.
These are just a few of the many adverse impacts these policy turnarounds have had around the world. It is unfortunate that the changes being made could not be done gradually with due consideration for the disruption they have caused. It also hurts the standing of the US on the global stage, especially when so many countries have benefited from their aid. It is possible that these opening salvos are just being done to put President Trump in a better bargaining position, and he may decide to continue most of the already-committed foreign aid and rejoin the WHO after he receives some concessions. Sadly, even if these changes are walked back to some extent, a lot of damage has already been done and many aid workers and physicians are now demoralized and face a lot of uncertainty.
From a policy standpoint, there are two lessons that countries like ours should learn. First, is that external funding will always be subject to the whims of the donor country and nothing is guaranteed. Political realities will always drive the willingness of any country to share its resources with the rest of the world. Diversification of funding streams for governments and non-governmental organizations is vital to remain viable in case of system shocks like what just happened. Second, is that countries should aim to be self-sufficient in health in the long run, and they should begin to wean themselves from third-party funders. Learning these lessons will result in more sustainable and resilient national healthcare systems. Hopefully, it will ensure that each country commits adequate resources to effectively care for the health of all its citizens, which is the mandate of any good government.
