Shared transnational challenges are supposed to bring the world together. The Covid-19 pandemic, however, has done the opposite, exposing the shortcomings of the structures that govern global health. At the start, countries scrambled in a free-for-all for medical supplies. They imposed travel bans and tightly guarded data about the novel disease. The World Health Organization (WHO), after struggling to secure Chinese cooperation, became a scapegoat for U.S. President Donald Trump, who announced that the United States would withdraw from the international health body.
U.S. President Joe Biden, promising to break with Trump’s retreat to vituperative nationalist politics, has signaled his intent to rejoin the WHO and revive the United States’ leading role more broadly. As welcome as those steps are, the Biden administration cannot simply pick up the mantle of U.S. leadership after it was discarded four years ago. Even before Trump’s presidency, American primacy in global health governance was ebbing. No one can turn back the clock to the bygone era in which the United States set the agenda.
The great health challenges of the twentieth century—including HIV/AIDS, malaria, and tuberculosis—affected poor countries more than wealthy ones. To address those diseases, the United States embraced a model of global health that resembled patronage, providing aid to institutions and countries. Washington shaped the international agenda through funding and its broad sway over multilateral health organizations, chief among them the WHO. In the twenty-first century, the United States has contributed about one-fifth of the WHO’s budget, much of it earmarked for specific programs that have been high priorities for Washington, including children’s health and infectious diseases. Likewise, U.S. bilateral global health funding over the last 20 years—the United States spent $9 billion in 2020 alone—has given Washington overweening influence over the health systems of recipient countries. The outsize U.S. role has made it hard for multilateral organizations to function effectively without tacit U.S. support. No doubt the money spent by the U.S. government has done tremendous good, but it has also allowed the United States to unilaterally set international health priorities and define the metrics of success, sometimes at the expense of what is actually needed on the ground.
But this model is now becoming obsolete. Unlike the health threats of the last century, the Covid-19 pandemic has reached nearly every corner of the globe. The United States cannot sit aloof from a troubled world, dispensing its benevolence and largess; it, too, is caught up in the crisis. At the same time, new networks and institutions, including philanthropies, regional organizations, and private companies, now play a major role in addressing global health challenges. Western researchers once steered the development of best practices and scientific knowledge in matters of public health; now scientists and organizations in the developing world wield influence, too. The technological revolution has generated many forms of new data that promise to transform the way governments and their health agencies work.
As a result, the governance of global health is becoming more decentralized, determined less by Washington’s prerogatives than by the combined work of governments, nongovernmental organizations, and private actors. In such a world, Washington must reimagine how it can lead: instead of trying to define the agenda, it must work with other governments, regional organizations, and the private sector to put partnership at the center of its efforts to protect public health.
African Union's Centers for Disease Control and Prevention (Africa CDC), director Dr. John Nkengasong (L) and Head of Communication at African Union Commission, Wynne Musabayana (R) hold a press briefing on the coronavirus cases in Africa, on March 10, 2020, in Addis Ababa, Ethiopia. (Getty)
THE CENTER CANNOT HOLD
The U.S.-led global health order of the past did achieve major victories, with the high-water mark being the bid by the George W. Bush administration in 2003 to end the HIV/AIDS epidemic through the program known as the President’s Emergency Plan for AIDS Relief (PEPFAR). Activists capitalized on the moral standing that the United States had gained in the wake of the 9/11 attacks to build an unprecedented coalition with conservative Christian policymakers. They launched PEPFAR with an initial budget of $15 billion over five years. Since then, Congress has reauthorized the program every five years. Having devoted to date over $95 billion, it remains the largest commitment of any government in history to address a disease and the largest commitment by the U.S. government to any cause since the Marshall Plan. It has been enormously successful, preventing, by one estimate, 18 million deaths.
But even as PEPFAR marked a seminal achievement in U.S.-led global health policy, it also pointed the way forward to a new world less dominated by the United States. PEPFAR adopted multilateral approaches from the outset, working with the WHO and the Bill & Melinda Gates Foundation to build the capacities of local health systems around the world. In recent years, PEPFAR has focused its work on 13 countries, and it intends to direct 70 percent of its future funding to partner organizations headquartered in poor countries, not in the capitals of the West.
That change in emphasis is revealing of a broader shift. The United States and the WHO no longer hold total sway over the governance of global health. When the WHO was founded, in 1948, there were few other organizations of its kind. But smaller, regional organizations now help lead the way in a more interconnected world. The Pan American Health Organization, for example, has funded immunization initiatives and supported health education programs across Latin America. And health agencies in South Korea and Vietnam have led far more effective responses to the pandemic than their counterparts elsewhere.
Africa has seen perhaps the most dramatic progress in coordinating a regional health policy. In 2017, the African Union’s members launched the Africa Center for Disease Control and Prevention. When an Ebola disease outbreak began in the Democratic Republic of the Congo in 2018, the Africa CDC supported six laboratories that conducted tens of thousands of tests and trained thousands of health-care workers. As the Ebola outbreak was ending in 2020, the Africa CDC shifted its focus to the Covid-19 pandemic, organizing the region’s response and helping distribute medical supplies across Africa.
The Africa CDC has actively pushed back against the old Western-centric model of global health. In April 2020, its director, John Nkengasong, refused to sanction a trial in Africa of a tuberculosis vaccine that might offer protection against the novel coronavirus. A French doctor had suggested in a televised discussion that such a vaccine should be tested in Africa because the continent had “no masks, treatment, or intensive care, a bit like we did in certain AIDS studies or with prostitutes.” The doctor later apologized, but the implication of Nkengasong’s refusal was clear: African countries, which have to date managed the pandemic much better than the United States and western European countries, will decide their own health priorities and ensure that medical studies conducted in Africa are led by African researchers in the interests of African peoples. Indeed, in November, 13 African countries launched the ANTICOV study, a joint effort to devise treatments for mild to moderate cases of Covid-19 in a bid to keep hospitalization rates down.
Meanwhile, in Geneva, the WHO has become an arena for geopolitical competition. As a membership organization, the WHO is vulnerable to the power dynamics among its member states, and China and the United States, in particular, have clashed over its decisions. The WHO made the mistake of appeasing China after the outbreak of Covid-19 at the end of 2019, presumably in an effort to gain better access to information about the progress of the disease. The WHO’s leaders applauded Beijing’s response to the virus and overlooked early missteps and the withholding of critical data, sparking outrage in the United States and elsewhere. China has played an increasingly large role in global health in recent years, both through bilateral initiatives—its vast investment project known as the Belt and Road Initiative includes health infrastructure projects around the world—and through support for multilateral programs. A country of China’s size must be engaged in these global efforts, but that engagement is most effective in the service of shared values and a broad, international consensus. Ironically, the U.S. decision a few months into the pandemic to withdraw from the WHO only made it harder for the international community to try to hold China accountable. The Trump administration’s abandonment of multilateralism played into China’s hands.
THE RISE OF THE PHILANTHROPISTS
Another powerful force remaking the governance of global health is the growing role of private and nongovernmental actors. The launch of the Gates Foundation in 2000 marked an important shift away from a model of global health centered on government action. In its first year of operation, the foundation spent $1.5 billion—orders of magnitude more than what any other organization of its kind had ever spent. The seismic impact of the Gates Foundation can be seen in a massive increase in global health spending, including at the WHO: the organization’s budget grew from less than $1 billion in 2000 to nearly $6 billion in 2020. In 2018, the Gates Foundation was the second-largest funder of the WHO, after the U.S. government. The Gates Foundation has used its financial muscle to drive improvements in vaccinations and other lifesaving therapies for the world’s poor. A private philanthropic organization having this much influence represents a sea change in global health.
Beyond philanthropies, a new kind of public-private partnership has arisen to address neglected problems at a time when many countries are struggling to provide basic health care to their citizens. Indeed, the cost of developing effective measures to fight future pandemics is prohibitively high for any individual country, but all countries benefit from the preparations of one. In 2017, a collection of private donors, pharmaceutical companies, and national governments launched the Coalition for Epidemic Preparedness Innovations. CEPI directs resources to develop vaccines against highly contagious diseases. The group has helped address some of the biggest challenges in pandemic preparedness, ones that were difficult for the WHO to tackle on its own. CEPI has supported the development of vaccine platforms—technologies that can be quickly adapted to create vaccines for new diseases. It has sought to broker deals between private pharmaceutical companies and vulnerable nations to ensure greater access to vaccines during outbreaks. In 2019, for instance, CEPI helped deploy experimental Ebola vaccines in the Democratic Republic of the Congo.
In 2020, with the pandemic raging, CEPI collaborated with Gavi, the Vaccine Alliance, a public-private global health partnership, and the WHO to launch the Covid-19 Vaccine Global Access Facility, also known as COVAX, an effort to distribute effective and safe vaccines to countries otherwise unable to procure them. As of January 2021, COVAX had over 180 participating countries—but not the United States, which joined Belarus, Russia, and a handful of island states in declining to join the initiative. In keeping with Trump’s “America first” foreign policy, this decision was one of several marking the administration’s position of “vaccine nationalism,” in which Washington saw the United States’ health interests as part of a zero-sum contest with other countries. Under Trump, the United States stood mostly alone in approaching vaccines for Covid-19 as a matter of purely national importance. Meanwhile, the rest of the world—with China playing a prominent role—has participated in multilateral initiatives to help distribute Covid-19 vaccines.
Entities such as the Gates Foundation, CEPI, and COVAX have not made the United States or the WHO irrelevant. Far from it. But in a world of increasingly diffuse power, no single player can drive the global health agenda. This is largely a good thing. And it provides the United States an opportunity to engage as a partner—rather than as a patron—encouraging collective action and countering parochial nationalism.
A medical worker collects a throat swab from a teacher for nucleic acid testing at a primary school on February 22, 2021 in Wuhan, Hubei Province of China. (Getty)
KNOWLEDGE IS POWER
As global health leadership has become decentralized and less reliant on the West, so, too, has medical scholarship. Advocates for “decolonizing global health” have long pointed to the disproportionate share of Western authors featured in global health journals, studies, and reviews; researchers and practitioners in poor countries that bear the greater burden of disease are often sidelined. But times are changing. Cutting-edge health and pharmaceutical research increasingly takes place outside the West. Chinese scientists who studied in the United States now run large, well-funded laboratories in China that are driving the next generation of scientific breakthroughs. Similar pioneering work is taking place in Southeast Asia and, increasingly, South Asia. In the years to come, African and Latin American scientists are poised to join their counterparts elsewhere in driving research forward.
Non-Western researchers are more often leading global health studies, particularly those presented in open-access publications—scholarship available to all for free. A 2019 analysis of medical research conducted in Africa—an area long dominated by Western scholars—found that 93 percent of infectious disease studies had at least one African author, and nearly half had an African lead author. As education and scientific capacity in the developing world improve, knowledge and best practices increasingly flow from poor countries to wealthy ones, bucking old colonial dynamics.
Private enterprises have also helped reshape the public health landscape in developing countries. The health technology company Baobab Circle, for instance, has introduced a popular app in sub-Saharan Africa that allows users to track their exercise, diet, and mental health and access online consultations with physicians. In Egypt, the startup TakeStep helps recovering addicts through telemedicine, allowing them to schedule appointments with counselors, psychiatrists, and clinicians. The Ugandan startup Matibabu has pioneered a device that can rapidly diagnose malarial infection (the cause of one million deaths globally per year) without requiring a blood sample. In India, Healthians delivers at-home tests for many diseases to rural communities that lack easy access to hospitals and clinics. Medicus AI, a company founded in Dubai, has designed an app that uses machine learning and artificial intelligence to explain complex medical diagnoses through user-friendly visualizations and recommendations.
The proliferation of technology-driven startups of this kind points to a new challenge in global health: managing the reams of health data that governments, health-care providers, and private companies produce. How data are generated, governed, and ultimately used will be the defining issue of global public health in the coming decades. Authoritarian countries have already started monitoring and controlling their populations by exploiting various data streams. Increasingly, multinational corporations are tapping into private data sources to build sophisticated models that will allow them to identify and respond to disease outbreaks. Yet government agencies in democratic countries are struggling to determine how best to use these data without violating ethical standards and legal protections. Worried about privacy, they have proved reluctant to utilize the data sets held by private companies. As a result, they have missed out on the huge potential for data-driven approaches to public health, ceding the field to authoritarian governments and private industry. Fortunately, the coronavirus crisis may compel a reevaluation of this approach, as the contrast between the inadequacy of conventional public health data streams and the effectiveness of the tools available to autocratic regimes and private parties becomes apparent.
Consider how China has responded to the pandemic. In addition to imposing lockdowns more rigid than those feasible in democratic countries, China deployed a surveillance system that uses various relatively new technologies—including location tracking, facial recognition, and QR codes that allow citizens access to public spaces only if they aren’t sick. In the early stages of the pandemic, for instance, the local government of Hangzhou introduced an app that assigned users a color code to indicate their health status. Only those with a green code—a clean bill of health—could enter subways, malls, and other public spaces. The app was decidedly opaque and invasive. Users, most of whom had not been tested for Covid-19, had no idea how determinations about their health status were made, and the app appeared to report users’ locations and other personal information to the police. It was as if the Centers for Disease Control and Prevention in the United States had used Facebook to track suspected Covid-19 patients and then quietly shared their user information with the local sheriff’s office. However disconcerting this approach was from a privacy perspective, it also allowed China to rapidly contain the virus.
Many Western countries, by contrast, continue to struggle to do so, in part because they are reluctant to resort to such invasive apps. The United States has lagged behind its European peers in gathering and sharing relevant data, including contact-tracing data and genomics analysis, and only a handful of U.S. states have enabled mobile phone contact-tracing capabilities. There are some signs of progress: the state of California has pioneered a Covid-19 exposure notification system that safeguards privacy by protecting users’ identities and blocking their locations. Facebook and Google have developed powerful tools for monitoring and responding to the pandemic, including community mobility data (analyzing anonymous data of the movements of people in a community) and symptom maps (tracking users’ reports of Covid-19 symptoms on social media). But the federal government remains missing in action. If the United States does not lead the implementation and mainstreaming of these technologies, the country will be forced to choose between meeting future health challenges blindfolded and adopting approaches developed by authoritarian governments that do not share U.S. constitutional values.
FROM PATRON TO PARTNER
After decades of setting the global health agenda and almost single-handedly funding key global health goals, the United States must adjust to being a partner in a broader, more decentralized system. This new partnership model should be understood as the inevitable result of long-term shifts, including the growing importance of private enterprise to public health, the increased role of China as a global power, and the decolonization of global health policy as more authority and resources are afforded to poor countries. Washington should not simply dwell on its lost standing and influence in the arena of global health governance. Instead, it should enthusiastically play a central and constructive role in this new order, working with a diverse set of partners to reform global health in ways that are consistent with American values.
As a first order of business, the United States must renew its commitment to the WHO. This does not mean that Washington should refrain from criticizing the WHO; indeed, reform of the organization, including encouraging the body to adopt a narrower, more focused agenda and granting it greater budgetary discretion to respond to emerging threats, must be a top priority of the Biden administration. But criticism will be meaningless without credible assurance that the United States will work to help the WHO succeed rather than simply walk away when the going gets tough.
Some argue that the WHO has become obsolete in the increasingly decentralized public health system, its consensus-based leadership cumbersome by comparison to ad hoc associations of countries and private entities. But in truth, the WHO is like a Rorschach test, with each of its different constituents seeing in it a different agency that should prioritize different goals. For wealthy countries, for example, the WHO represents an opportunity to shape the global health agenda and keep disease outbreaks at bay. For less wealthy countries, the WHO is a lifeline, providing crucial technical assistance and helping eliminate diseases such as polio. Too often, the WHO tries to be all things to all countries, ensuring that it is effective in few of the objectives it pursues.
A clearer, more streamlined set of responsibilities would allow the WHO to build stronger capacities to monitor infectious disease outbreaks and share critical health data among countries. Having a more coherent agenda would help the organization secure more stable funding. The WHO must do the things that only it can do, including setting shared global health norms and targets and coordinating responses to transnational health threats. Its leadership, with full input from its member states, must ensure that such reforms aren’t merely cosmetic; they must recast the WHO to meet modern challenges.
The United States should not make the WHO a battleground of geopolitical competition with China; instead, it should encourage the organization to adopt higher standards in several crucial areas, including data transparency. New data streams are essential to building modern surveillance systems for disease outbreaks. For instance, in 2020, using mobile phone data, investigators highlighted the role of informal cross-border migration in the transmission of malaria in Bangladesh. The WHO must recognize both the importance of these kinds of data and the necessity to shape the norms around their use. The body’s current approach relies on more traditional data sources and methods of modeling disease that are inadequate to prepare for current threats. Indeed, the assessments the WHO had made before Covid-19 of various countries’ pandemic preparedness were often completely wrong; some of the ostensibly best-prepared countries (notably the United States) have had the worst responses to Covid-19.
Beyond the WHO, the United States should invest in the growing diversity of the global health governance ecosystem by supporting new public-private entities. It should help fill niche gaps by, for example, supporting the Foundation for Innovative New Diagnostics, which develops diagnostic tests for diseases that may spark pandemics, and allow the WHO to concentrate on a limited set of core competencies. Washington should expand its global health partnerships with entities such as the Africa CDC to improve public health in the developing world, promote American soft power, and strengthen the ability of poor countries to respond to disease outbreaks. A top priority of U.S. global health investments must be building the capacity of researchers and public health leaders in the developing world through prepublication support (offering advice and technical assistance to researchers), research partnerships, data sharing, and policy collaboration as peers. And the United States must help ensure that the information generated by the technological revolution, much of it in private hands, can be used for the good of public health without infringing on democratic values and individual rights.
In the twentieth century, global health challenges were rarely truly global. Instead, they were typically confined to particular countries or regions. But in the twenty-first century, threats to health affect the entire world. The United States needs to recognize that the centralized approach to global health that it dominated and the WHO managed is no longer viable. The era of U.S. agenda setting may have ended, but that only increases the importance of U.S. leadership. In years past, American priorities inevitably shaped global health; today, if the United States wants future global health initiatives to reflect its values, it must collaborate with others and seek to lead through partnership.
This article was originally published in the March/April 2021 issue of Foreign Affairs Magazine and on ForeignAffairs.com.
