Abstract
The World Health Organization (WHO), the body charged with implementing global pandemic response, figured heavily in the Republican and Democratic campaigns of the 2020 US presidential election. The contrast was stark: Donald Trump drew on and ramped up dissatisfaction with the United Nations system in general and the WHO in particular, culminating in his decision to pull the US out of the WHO in the middle of the pandemic, while Joe Biden rescinded the decision to leave the WHO the day after assuming the presidency. Despite this difference, neither party heeded renewed calls during COVID to put health justice and primary healthcare at the heart of global health policy. Both parties continued to prefer private philanthropic sources of funding for global vaccine initiatives, and both sought economic returns on vaccine development, potentially missing a rare opportunity to incorporate global health justice into US global health diplomacy.
I'll just have to save him. Because, after all, a person's a person, no matter how small.
—Dr. Seuss, Horton Hears a Who!
US Global Health Diplomacy: Different and the Same
In the United States of America in 2020, a polarized polity fought the COVID-19 pandemic as more grist to its mill, with deadly effect. It was a US presidential election year, with the incumbent Republican Donald Trump running against the Democratic candidate Joe Biden. The national context was one of crisis: heightened attention to racial violence, ongoing climate crisis, and multiple social and economic crises exacerbated by the global pandemic that were fueling already deeply entrenched health, economic, housing, and educational inequality. Within and between the United States and other nations, health disparities and health-care systems revealed themselves as critical in defining and stratifying the contemporary world. During the year, Donald Trump drew on and ramped up older US and Republican dissatisfaction with the United Nations system in general and the World Health Organization (WHO) in particular, culminating in his decision to pull the United States out of the WHO in the middle of the pandemic. On January 21, 2021, a day after Joe Biden assumed the US presidency after campaigning for a pro-science approach to containing the virus, the new administration rescinded the decision to leave the WHO.
Global health diplomacy is an actor's category in the United States government: it is the term used by the government to describe “the intersection of public health and foreign affairs” to “leverage a widely agreed upon goal—a healthier, safer world” “to develop the foundation for diplomatic relations in other sectors.”1 The US Department of Health and Human Services describes global health diplomacy as “core” to the activities of the Office of Global Affairs, the main US government liaison with the World Health Organization. Despite the Trump administration's ongoing fight with the WHO, the government website continued to highlight liaising with the WHO and representing the United States at WHO's annual World Health Assembly, along with global health security and health attachés, right up through the end of Trump's term.
President Trump's attacks on the World Health Organization included two main themes: a bureaucratic operational attack against the WHO's alleged slowness to act in the early days of the pandemic, and a geopolitical attack against the WHO's alleged favoring of China. These attacks peaked in the late spring with the threat by the United States to withdraw from the WHO—followed by its withdrawal during the country's worst phase of the pandemic to date. At the end of August, the United States missed the deadline for higher-income economies to express interest in joining the global vaccine financing and sharing initiative, COVAX, citing WHO's involvement as the major reason not to participate.2 By September 2020, the Trump administration's plans for a 2021 US withdrawal from the WHO were in place.
Biden's COVID-19 policy differed sharply and included an embrace of global health obligations that led to his administration joining COVAX shortly after his inauguration. The Democratic campaign centered being science led, in contrast to the antiscientific sentiment purportedly behind right-wing vaccine, masking, and social-distancing skepticism. While Biden's version of global health diplomacy made health-care access and science central, it continued to emphasize that global vaccine access served to prevent infectious diseases from spreading to the United States from overseas and continued to support public-private partnerships aimed at US vaccine innovation over government aid or a global health justice framing. Despite supporting the WHO, Democratic US global health diplomacy fell short of the more substantive commitment to global health justice that the World Health Organization, under Director-General Tedros Adhanom Ghebreyesus, saw as a big opportunity of the new pandemic era.
Timeline
JANUARY 2020: PUBLIC HEALTH EMERGENCY OF INTERNATIONAL CONCERN
The International Health Regulations (IHR) of 2005 are an instrument of international law that govern the designation of and global response to pandemics. They are legally binding on the 196 signatory countries, including the United States. The treaty empowers the World Health Organization to act as the main global surveillance and information system when there is a public health emergency that crosses national borders.3 Under the IHR, nations have twenty-four hours to report a suspected public health emergency of international concern (World Health Organization 2005).
On January 21, 2020, the WHO issued its first “Situation Report” on the “Novel Coronavirus (2019-nCoV)” in which it documented the first 282 confirmed cases, centered in Wuhan, China, and including those spread by travel to other Chinese cities and to Korea, Japan, and Thailand (World Health Organization 2020c). The report states that China first informed the WHO of the outbreak on December 31, 2019. It also states that China had isolated the virus and had shared the genetic sequence with the WHO for the purpose of diagnostic kit development by January 7, 2020. There is no speculation as to the origin of the virus or its modes of transmission. The report confirms that the WHO activated the “R&D blueprint to accelerate diagnostics, vaccines, and therapeutics” as soon as it was informed, and was not just working with affected countries but was already “working with our networks of researchers and other experts to coordinate global work on surveillance, epidemiology, modelling, diagnostics, clinical care and treatment, and other ways to identify, manage the disease and limit onward transmission,” and had already “issued interim guidance for countries” (World Health Organization 2020c: 3).
By January 30, 2020, the WHO had declared the novel coronavirus a “public health emergency of international concern,” or PHEIC, the highest formal level of global alarm under the IHR. The term pandemic is not used in the IHR. The monthlong delay between the December 31, 2019, alert and the January 30, 2020, declaration was due at least in part to the way the International Health Regulations work despite recent efforts in response to Ebola and H1N1 to tighten and streamline global responsiveness. For the WHO to declare a PHEIC, there needs to be “an extraordinary event which is determined to constitute a public health risk to other States through the international spread of disease and to potentially require a coordinated international response,” and the situation needs to be “serious, sudden, unusual or unexpected” (World Health Organization 2005: 9). Despite the requirement that member states report suspected PHEICs within twenty-four hours, the actual PHEIC declaration cannot be made until an emergency committee has been formed and has reported back. For COVID-19, this committee held its first meeting January 22–23 and, as noted above, a PHEIC was declared on January 30. The United States was represented on this committee.4
On January 31, 2020, President Trump imposed a travel ban on passengers arriving from China, except for US citizens and permanent residents and their immediate family. In the following days, WHO's Director-General Tedros responded by condemning travel bans for passengers arriving from China barring further evidence.
FEBRUARY 2020: IN CHINA, “PREPARE TO . . . TRIGGER THE ALL-OF-GOVERNMENT AND ALL-OF-SOCIETY APPROACH”
The next formal step, an international on-the-ground discovery mission to Wuhan and other provinces, did not take place until February 16–24. Twenty-five nations, including the United States, sent experts. In his opening remarks at the February 24 press briefing, WHO Director- General Tedros stopped short of calling COVID-19 a pandemic, saying that although COVID-19 had the potential to become a pandemic, the full criteria had not yet been met, and “a tailored response” to epidemics in different countries was still the best global policy (Ghebreyesus 2020). On February 26 the “Report on the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19)” was released (World Health Organization 2020b). Among many findings, the report recommended that even nations without any instances of COVID-19 to date “prepare to immediately activate the highest level of emergency response mechanisms to trigger the all-of-government and all-of-society approach that is essential for early containment of a COVID-19 outbreak,” “begin now to enforce rigorous application of infection prevention and control measures,” and “engage clinical champions to communicate with the media.” For critics, mid-February was too late to have let outsiders in to inspect on the ground and the WHO was too trusting of—perhaps even in collusion with—China. There were also reports of restrictions on expert members from the United States. Supporters of the IHR process endorsed the principle that international organizations should not rush into sovereign territory without following their own transparent and accountable processes carefully.
The reluctance to declare a pandemic was seen by many as obfuscating and deadly: had a pandemic been declared more quickly, the spread of COVID-19 might have been curtailed and lives might have been saved. Others, however, felt that not rushing to use the term pandemic helped steer the global response toward facts rather than alarmism. One reason for the delay in declaring COVID-19 a pandemic was the underdetermined definition of a pandemic. Dr. Anthony Fauci, director of the US National Institute of Allergy and Infectious Diseases, explained in his own briefing during the February 16–24 meeting that the word pandemic “really is borderline semantics, to be honest with you” (Howard 2020).
MARCH 2020: PANDEMIC DECLARED
For the WHO, naming something a pandemic is operationalized into six steps (World Health Organization 2009). Step six requires that infections be sustained among multiple countries in at least two WHO regions. According to this operational definition, the declaration of a pandemic was justified by the spread of sustained infection rates from the Western Pacific region into the European region in early March. Before the second week in March when European cases took off, it was only individual countries outside of the Western Pacific region such as Iran, the United States, Italy, and France that had confirmed cases, and they did not appear to be linked to one another through independently sustained transmission. This changed in early March, and on March 11 the WHO declared COVID-19 a pandemic. To underscore that the last of the WHO criteria for the pandemic declared two days previously had been met, WHO designated Europe as the new epicenter of the pandemic on March 13. On March 25, the WHO identified the United States, in the Americas region, as the third regional epicenter.
APRIL 2020: US BREAK WITH THE WHO
On April 14, 2020, President Trump gave a press conference at which he confirmed a threat he had made the previous week to withhold funds from the WHO, saying, “Today I'm instructing my administration to halt funding of the World Health Organization while a review is conducted to assess the World Health Organization's role in severely mismanaging and covering up the spread of the coronavirus,” because of the WHO's “disastrous decision to oppose travel restrictions from China and other nations” (Trump 2020a). This Rose Garden briefing framed the dispute around the purported failure of the WHO to “ensure that accurate information about international health threats is shared in a timely manner,” and the claim that WHO “willingly took China's assurances at face value,” as well as opposition to lifesaving travel restrictions. Trump also returned repeatedly to the long-standing question of the large share of WHO's running costs that the United States foots relative to China and the obligation to taxpayers to make sure that their money is being spent in the best way to fight the virus at the least cost to the nation. Answering questions from reporters, Trump reiterated that the United States had had problems with the WHO for a long time and should have done something about it long ago.
MAY 2020: WITHDRAWAL TRIGGERED, FUNDING WITHHELD
On May 18, President Trump sent Director-General Tedros a four-page letter criticizing the WHO's response in the early phases of COVID-19.5 The letter argued that China knew about, and WHO ignored, reports that conflicted with the official Chinese version “days or weeks earlier” than the December 31 notification of the WHO. The letter cites turning a blind eye to the suppression of Chinese whistleblowers, the WHO's complicity in Chinese attempts to downplay the virus through obfuscation about the need for travel bans and the possibility of asymptomatic spread, and WHO's praise of China's supposed transparency as evidence of a cover-up and collusion with China. The lateness of the February 16 date for outside observers to be let into China (and several days later, Wuhan) and the failure to intervene when the two American experts were barred from visiting Wuhan suggested that WHO was not prepared to put pressure on China's sovereignty. Tedros's WHO is criticized for being less effective than Gro Harlem Brundtland's WHO during the 2003 SARS outbreak when the WHO imposed travel restrictions around the Southern Chinese epicenter and openly criticized China for suppressing information.
On May 29, 2020, President Trump announced that the United States would cease its funding of the WHO. In the same speech, he announced the ending of special status protections for Hong Kong, framing both policies as concerned with “our relationship with China and several new measures to protect American security and prosperity” (Trump 2020b). According to Trump, “China has total control over the World Health Organization, despite only paying $40 million per year compared to what the United States has been paying”; “because they have failed to make the requested and greatly needed reforms,” withdrawing was the only diplomatic option remaining.
AUGUST 2020: PUBLIC-PRIVATE PARTNERSHIPS, NOT INTERNATIONAL ORGANIZATIONS
Over the summer of 2020, the WHO worked with international philanthropic organizations and other partners to address vaccine equity around the world through the Access to COVID-19 Tools (ACT) Accelerator. The vaccines pillar of ACT, COVAX, was launched as “a global risk-sharing mechanism for pooled procurement and equitable distribution of eventual COVID-19 vaccines.”6 COVAX was jointly set up by the global vaccine alliance known as GAVI, by the Coalition for Epidemic Preparedness Innovations (CEPI), and by the WHO. August 31, 2020, was the deadline for higher-income economies to submit “Expressions of Interest” to join the global vaccine financing and sharing initiative. The United States joined China and Russia in missing the deadline to sign on as a higher-income nation-state, with President Trump citing the WHO's involvement as the major reason not to participate. GAVI, and to a lesser extent CEPI, continued to receive massive amounts of US private sector, philanthropic, and state funding, however, underlining the symbolic significance of not joining the major effort to address vaccine equity and distribution worldwide as a nation-state, while moving ahead with private philanthropic and bio-innovation funding.
SEPTEMBER 2020: ELECTION PLATFORM AND GENERAL ASSEMBLY
On September 2, 2020, Nerissa Cook, the deputy assistant secretary of the Bureau of International Organization Affairs, joined Garrett Grigsby of the Department of Health and Human Services Office of Global Affairs and Dr. Alma Golden from Global Health USAID for an official briefing on the World Health Organization. Coming just weeks before the 2020 US presidential election, this special “Briefing on the US Government's Next Steps with Regard to Withdrawal from the World Health Organization” constituted President Donald Trump's behind-the-tweets election position on the WHO (US Embassy Tbilisi 2020). The fact that Trump himself did not take part in this briefing went some way to returning health diplomacy to its more usual behind-the-scenes status. The briefing began by addressing the relationship between the WHO and China, saying that “the President gave WHO the opportunity to embrace crucial reforms, most notably to demonstrate its independence from the Chinese Communist Party. WHO declined to take that opportunity, resulting in . . . notice of withdrawal from the WHO effective on July 6, 2021” (US Embassy Tbilisi 2020).
From there, the briefing turned to funding, announcing that the remainder of the 2020 annual assessment of WHO funding would be diverted to pay the United States’ assessed contributions to other UN organizations. The representatives from USAID and HHS then emphasized the high level of US overall spending on global health and detailed the voluntary contributions working with partners including the WHO that the United States would continue to make to programs dealing with infectious disease outbreak and dangerous pathogen preparedness and control, as well as some humanitarian efforts spearheaded by the WHO. “The United States will participate in specific meetings of the WHO's governing bodies and technical and advisory committees,” although it was not spelled out how without paying membership dues they would keep a seat at the table, and “priorities will be events and processes of a normative, regulatory and standard-setting nature that have a direct impact on Americans, on US national security, on US economic interests, US companies, and on the US Government's global health investments” (US Embassy Tbilisi 2020).
JANUARY–FEBRUARY 2021: BIDEN AND HARRIS REVERSE THE CALL
In one of his first acts as president, Joe Biden signed a letter to António Guterres, Secretary-General of the United Nations, retracting outgoing President Trump's decision to withdraw from the World Health Organization.7 The following day, January 21, 2021, Vice President Kamala Harris called Director-General Tedros to discuss the United States’ decision to reverse its withdrawal from the WHO and to revive the relationship.8 The following month, on February 18, 2021, Biden announced that his administration had joined the global vaccine alliance and COVAX.9
The Other
President Trump imposed his first restrictions on travelers from China to the United States on January 31, 2020. Securing borders seemed to many to flow from the declaration of a public health emergency of international concern; other countries, including China and New Zealand, that came to be associated with very different politics as the pandemic progressed, also quickly imposed travel restrictions. National borders were a self-evident first line of defense against disease regardless of COVID-19’s epidemiology and other characteristics, and travel bans signified tough action (Radil, Castan Pinos, and Ptak 2021).
Throughout the pandemic, national, regional, and demographic self- and other- characterizations were wielded strategically and were often nationalist and xenophobic. For Trump, emphasizing the Chinese origins of COVID-19 and reminding the public of his early China travel ban allowed him to claim repeatedly that he acted fast and that the WHO had acted too late and too favorably to China. This became both his own defense and the basis of his attack on the WHO. It also underwrote the other key element of Trump's COVID-19 global health diplomacy: within-border advantage. Trump juxtaposed his speed in imposing key travel bans with downplaying all kinds of within-nation risks. Opposing a foreign invasion while resisting domestic restrictions emerged as a two-fronted narrative of freedom and strength.
At home Trump promoted a business-centric nationalism based on harnessing US biomedical breakthroughs primarily for the benefit of Americans and the US economy. Restrictions on public movement and behavior were delegated to the states and to health-related parastatals like the Centers for Disease Control and Prevention while being ideologically consigned to the Left. He was thus able to portray Democratic calls for national efforts at controlling behavior as government overreach and socialism. This elision between partisan politics and fighting the pandemic meant the two sides continually talked past each other, with Democrats (despite representing many constituencies who have reason to be skeptical of the state-like power of technoscience) trying to make the debate about following science and protecting the vulnerable, while Trump made it about strong leadership; public-private solutions such as his rapid vaccine development and deployment program, Operation Warp Speed; and freedom from government overreach.10
The Democratic Party seized on the ethno-racial and ethno-national aspects of President Trump's COVID-19 response evident in the nations targeted by early travel bans and Trump's continuing references to the “Wuhan virus” and “Chinese virus,” and many Americans, including many Asian Americans, condemned the terms as racist and reported increased anti-Asian hate related to COVID-19. Democrats emphasized that mask wearing, social distancing, and vaccines protected not just the individual but also any vulnerable people with whom one might come into contact, construing noncompliance not as personal freedom but as a callous disregard for those with disabilities or the elderly. They downplayed the disproportionately negative effect that compliance was having on the education and living conditions of lower-income children, families, and workers.
Charges of racism around the pandemic crossed borders. The United States charged China with racist actions against African nationals in China in the name of pandemic control. Some Taiwanese took to social media to condemn Tedros, the first African Director-General of the World Health Organization, using racist epithets. And across the globe, the ethno-racial, national, and class parameters of excess death and illness from COVID-19 were becoming clear. The dependence of the richest nations on structural inequality and migration for staffing health infrastructure was ever more evident. As the professional classes began to work from home, the class and racial geographies of essential in-person jobs underlay differential death rates. In many wealthier neighborhoods, frontline jobs such as supermarket checkout positions shifted demographics seemingly overnight. Hot spots of coronavirus infection in meatpacking plants, in seasonal agricultural laborers’ living quarters, on board leisure and military ships, in prisons, and in nursing homes, and the names of towns like Marion, Ohio, and Sioux Falls, South Dakota, revealed a geography only hazily known by most Americans: the transnational and domestic hinterlands of everyday racial capitalism (Burden-Stelly 2020).
Public versus Private Funding for Global Health
The global vaccine alliance GAVI was founded in 2000 with $750 million in seed money over five years from the Bill and Melinda Gates Foundation. Closeness to the Gates Foundation and an increasing dependence on targeted voluntary contributions to fund the WHO had already swung the WHO's infectious disease focus away from addressing structural health inequality and toward an emphasis on vaccines.11 This change occurred despite the significance of the shift to global primary health care and the social determinants of health present at the WHO alongside older concerns with international security and infectious diseases containment at least since the Alma-Ata Declaration of 1978.12 The influence of entities like the Gates Foundation, together with the WHO's perceived paternalism, underlies some of the post- and decolonial critique of the WHO (Amri et al. 2021; Kalkan and Madi 2022). GAVI's secretariat is a stone's throw from the WHO in Geneva. CEPI is headquartered in Oslo, Norway, and was launched in 2017 at the World Economic Forum in Davos, Switzerland. It was cofounded and cofunded with US$460 million from the Bill and Melinda Gates Foundation, the Wellcome Trust, and a consortium of nations including Norway, Japan, and Germany, which the European Union (2019) and Britain (2020) subsequently joined. GAVI especially, but also CEPI, are thus heavily US funded and driven by the wealth of the Global North.
Allowing US “Billanthropy” (named for the Bill and Melinda Gates Foundation's outsize effect on health funding globally) to continue to invest heavily in GAVI, ACT, and COVAX without committing taxpayer money was consistent with Trump's view that nations’ obligations toward others are best thought of first and foremost as rooted in protecting health, wealth, and national security at home. Global health investment in the framework of public-private biomedical innovation funding makes it likely that contributions will be recouped through sales of American technologies, vaccines, and intellectual property thus developed and deployed.13
The Biden administration maintained that “no nation can act alone in the face of a pandemic,” and coupled “support[ing] the world's most vulnerable and protect[ing] Americans from COVID-19,” which appeared at least normatively to support the idea that the health of others elsewhere is a matter of US concern in its own right.14 His administration's reversal in pledging support to GAVI and COVAX recognized that the United States, as a wealthy nation, has an obligation to contribute to global health care. Strikingly, though, Biden's actual commitment to GAVI and COVAX remained centered around “vaccine procurement and delivery,” “donor pledges,” a “commitment to global health security” and “sustainable health security financing,” and “a leadership role galvanizing new donors,”15 demonstrating how closely his global health diplomacy in fact mirrored that of the previous administration.
Dr. Tedros Adhanom Ghebreyesus assumed the role of the eighth director-general of the World Health Organization in July 2017, just months after Donald Trump was inaugurated. Tedros is an Ethiopian biologist and public health researcher and former health minister. The WHO director-general position is decided by a membership vote and top contenders mount extensive global political campaigns to lobby for votes. In the 2016–17 campaign, the United States sided with the UK and Canada in supporting the candidacy of insider David Nabarro, a British physician and international civil servant, in the final stages. Nonetheless, Tedros was swept to power with a huge majority, backed by a coalition of African and Asian countries including China. Whereas Nabarro wanted to hone the WHO for response to outbreaks and health emergencies, Tedros's platform centered health care for all.
There have been many calls originating from countries such as the United States, home of the Gates Foundation; the United Kingdom, Nabarro's home country; and Switzerland, home to the WHO headquarters, to reform the bureaucracy and financing of the WHO (Moser and Bump 2022) just as there have been calls originating in countries who were part of the coalition supporting Tedros to emphasize global health inequities and critiquing the paternalistic and colonial aspects of the WHO. Both the Biden and Trump versions of global health diplomacy—their shared emphasis on private-public partnerships, bio-innovation, Billanthropy, and economic and geopolitical efforts to protect US citizens through global health security—were better aligned with the Nabarro platform, whereas Tedros was predisposed to collaborate with China and the Asian and African alliance that brought him to power.
The Taiwan question rumbled on in the background of the 2020 dispute between President Trump and the World Health Organization. Since the Chinese permanent seat on the UN Security Council and membership in the UN was transferred from the Republic of China (Taiwan) to the People's Republic of China (PRC) at the General Assembly in 1971, Taiwan has had neither membership in UN organizations including the WHO nor been de facto controlled by the PRC, even though Resolution 2758 recognized the PRC as the sole Chinese representative for both the PRC and the Republic of China.16 This has left Taiwan, a major ally and US trading partner, unrepresented. Given the early spread of the COVID-19 pandemic, it was not surprising that Taiwanese doctors, politicians, and activists felt the irony of being shut out of the UN system especially acutely and argued again for resolving the Taiwan question. In April, Tedros complained of having received racist tweets from Taiwanese accounts; Taiwan's leadership responded by saying that the social media accounts were fake and “probably trolls from China, based on digital footprints” (Yang 2020).
Sovereignty and Dues
Every aspect of the 2020 US-WHO fight drew some of its animus and contours from older roots. Like the selection process and priorities described above for the director-general of the WHO, the relationship between the United States and international treaties in general is relevant. There is a long-standing US concern with ceding sovereignty to international organizations and legal instruments, and the United States is notoriously nonsignatory to a multitude of international treaties on human rights, labor protections, arms limitation, and the environment, among other areas. The US delegation filed a Note Verbale in 2006 during the most recent revision of the International Health Regulations treaty to register three reservations. These reservations—that US federalism be respected in applying IHR, that national security interests might trump treaty obligations, and that the US believed the treaty does not adequately address private rights—could be found underlying the Trump administration's rhetoric during the COVID-19 pandemic.17
Another genealogy of relevance here is the question of the fairness and value for money of the funding provided by the United States to the WHO. As discussed above, Trump made it clear early on that he believed the United States pays more than its share and that it was not getting value for money during the pandemic. Tedros, on the other hand, emphasized the WHO's value for money during the pandemic. Both Nancy Pelosi, the Democratic congresswoman from California and speaker of the United States House of Representatives, and Joe Biden were quick to condemn and question the legality of Trump's withdrawal of the United States from the WHO. Yet while the US Democratic Party was in favor of reversing the threatened withdrawal, they remained quiet about the question of sustainable funding for the WHO.
The United States complains about its share of the WHO dues because of the way dues are calculated. The WHO is funded by a combination of core operating funds known as assessed contributions that each member state pays, and voluntary contributions from various partners. Voluntary contributions are frequently restricted to reflect the funding partners’ interests. Assessed contributions, on the other hand, are fully flexible, allowing for predictability, sustainability, and some independence from a wealthy donor base, so they remain vital even though their share of the total budget has recently declined to only approximately one-quarter of total WHO funding. Wealthy countries and their private and health philanthropic sectors have favored the voluntary contribution category in recent years because it can be directed by the donor to projects and approaches that build markets at home. It is the assessed contributions that attracted Trump's ire. Assessed contributions are calculated in relation to a nation's wealth and its population, leading to some arguably anomalous assessments. Of most relevance to this article, in 2020, the United States was assessed the largest contribution, at 22 percent of the total, while China came in second, but was only assessed 12 percent of the total. China's percentage was much smaller than the US percentage because of its large population, by which its wealth measure was divided. There is no corrective for cost of living, leading many to feel the United States overpays relative to China, just as Trump maintained. Many nations, however, note that the United States could afford to pay, and point to the fact that the United States is frequently in arrears on its assessed contribution. Funding is constantly under discussion at the WHO, but it is not likely in the short term that the United States under any administration will willingly pay its assessed contribution during economically turbulent times, even though the US share of voluntary contributions (including those provided by US philanthropic and private-public donors) is likely to remain high.
The United States and the WHO in Pandemic Times: A Lost Opportunity for Better Global Health Justice?
I argued above that Trump's and Biden's platforms were radically different in some regards, but that there remained distinct and deep overlaps. US global health policy under both parties stopped short of assuming that a wealthy nation has fiscal responsibility for the health of others elsewhere by virtue of their humanity or human rights, instead translating overseas obligations into pandemic control, national security, and trade advantages at home. And both emphasized private-public innovation over public US commitments to global health.18 Thus both departed from the views of much of the rest of the world and remained at odds with powerful elements of the current WHO directorate and its backers who saw the pandemic as making the case for global health justice and equity. Trump's outright rejection was exceptionalist though it drew on older tensions. Biden's milder version resonated with Nabarro's international lobbying efforts for the WHO leadership and all the important players in that campaign remain significant in the global pandemic and vaccine landscape. With time, underlying similarities have become more apparent. In December 2022, COVAX was folded back into regular GAVI activities. In February 2023, for example, the US Energy Department shifted—albeit with a low level of confidence—from viewing COVID-19’s origins as “natural” (i.e., from a market) to seeing them as manufactured (i.e., from a lab leak during gain of function experiments at the Wuhan Institute of Virology). The WHO and China immediately dismissed and denounced this shift in the Biden administration's position as aimed at provoking China.
Bringing US global health diplomacy more in line with much of the rest of the world would require a willingness to see things like indigenizing intellectual property and rethinking global trade as major constituents of long-term global health. While there are scholars and activists and particular programs within international organizations, nongovernmental agencies, and even for-profit initiatives that do work to make these wider connections, centering them in US national global health policy remains elusive. Politically, it is unlikely that the distance between US global health diplomacy and advocacy for redressing global health disparities will ever be addressed directly by any US administration unless US concerns about the funding and governance structure of the United Nations and the WHO are acknowledged and addressed. And unless decolonizing critiques can be given a global platform, the overriding effect of the capital involved in the bio-innovation model is likely to continue to obscure what is meant by and needed from global health equity.19 It thus remains unclear whether current US global health diplomacy of either political party can permit a robust discussion of a potential US role in a more redistributive model of global health diplomacy, let alone bring a genuine choice to the electorate.
Notes
US Department of Health and Human Services, “Global Health Diplomacy,” www.hhs.gov/about/agencies/oga/global-health-diplomacy/index.html (accessed May 29, 2023).
Gavi the Vaccine Alliance, “COVAX,” www.gavi.org/covid19/covax-facility (accessed May 29, 2023).
The Constitution of the World Health Organization was adopted by the International Health Conference held in New York in summer 1946; it was signed by sixty-one states. It entered into force in April 1948. Article 1 states that “the objective of the World Health Organization shall be the attainment by all peoples of the highest possible level of health” (World Health Organization 2020a).
The United States was represented by Dr. Martin Cetron, Director, Division of Global Migration and Quarantine, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta. The full membership and statements to date of the COVID-19 IHR Emergency Committee can be found at www.who.int/groups/COVID-19-ihr-emergency-committee.
Donald Trump to Tedros Adhanom Ghebreyesus, May 18, 2020, https://trumpwhitehouse.archives.gov/wp-content/uploads/2020/05/Tedros-Letter.pdf.
Gavi the Vaccine Alliance, “COVAX,” www.gavi.org/covid19/covax-facility (accessed May 29, 2023).
Joseph R. Biden Jr. to António Guterres, January 20, 2021, www.whitehouse.gov/briefing-room/statements-releases/2021/01/20/letter-his-excellency-antonio-guterres/.
“Readout of Vice President Harris's Call with World Health Organization Director-General Dr. Tedros Adhanom Ghebreyesus,” January 21, 2021, www.whitehouse.gov/briefing-room/statements-releases/2021/01/21/readout-of-vice-president-harriss-call-with-world-health-organization-director-general-dr-tedros-adhanom-ghebreyesus/.
“Fact Sheet: President Biden to Take Action on Global Health through Support of COVAX and Calling for Health Security Financing,” February 18, 2021, www.whitehouse.gov/briefing-room/statements-releases/2021/02/18/fact-sheet-president-biden-to-take-action-on-global-health-through-support-of-covax-and-calling-for-health-security-financing/.
US Department of Health and Human Services, “Explaining Operation Warp Speed,” August 2020, www.nihb.org/COVID-19/wp-content/uploads/2020/08/Fact-sheet-operation-warp-speed.pdf.
I was an invited speaker at the 2008 “Science against Poverty” conference when Spain held the presidency of the European Union. My panel included a top official from the Gates Foundation and the head of the WHO's vaccine program; I was the only one to suggest broad-reaching antipoverty interventions as most beneficial for health inequality; by the time our panel's conclusions had been reported out to the secretariat, only vaccines remained.
World Health Organization, “WHO Called to Return to the Declaration of Alma-Ata,” www.who.int/teams/social-determinants-of-health/declaration-of-alma-ata (accessed May 29, 2023).
The United States outspends other industrialized countries despite worse health outcomes and systemic health disparities (Tikakanen and Abrams 2020).
“Fact Sheet: President Biden to Take Action on Global Health through Support of COVAX and Calling for Health Security Financing,” February 18, 2021, www.whitehouse.gov/briefing-room/statements-releases/2021/02/18/fact-sheet-president-biden-to-take-action-on-global-health-through-support-of-covax-and-calling-for-health-security-financing/.
“Fact Sheet: President Biden to Take Action on Global Health through Support of COVAX and Calling for Health Security Financing,” February 18, 2021, www.whitehouse.gov/briefing-room/statements-releases/2021/02/18/fact-sheet-president-biden-to-take-action-on-global-health-through-support-of-covax-and-calling-for-health-security-financing/.
The text of United Nations General Assembly Resolution 2758 is available at china.usc.edu/resolution-restoration-lawful-rights-peoples-republic-china-united-nations-1971.
The International Health Regulations US note to depository can be read at https://2001-2009.state.gov/s/l/2007/112669.htm.
This article's epigraph, from the Dr. Seuss (Theodor Geisel) book Horton Hears a Who! (1954), hails from a similar post–World War II context to that in which the WHO (1948) came into being. The quote is frequently used to indicate standing up for the vulnerable and yet it is highly contested in ways that resonate with the themes of this article. Pro-life advocates have used it in the context of abortion, while others have pointed to Seuss's own desire in the book to distance himself from his anti-Japanese war work, and yet others have noted the paternalism and colonial tropes evident in the text and illustrations.
The ten top contributors in assessed and voluntary contributions to the WHO in 2021 were, in order: Germany; the Bill and Melinda Gates Foundation; the United Kingdom; the European Commission; the United States; GAVI; Saudi Arabia; Japan; the United Nations Foundation; and the World Bank. These nations and bodies are heavily invested in health innovation.
/5/m_coverimage.png?Expires=1731817696&Signature=FoeHftX~LBxpQ~taRXRXytcNYnMAvzPCha4Gm6igGANCJWvw475zrG~eNef-~d16KNHlaIbQgxTpnE6n5EHj1wy1YH4RtGC~Oe26S-p4PE15yIAElzwsjC1xF3edDfFee1FoJXttErIfWLorv9Fr1sfbZ4XVw1HAcsrFFdWfTKo83uRiuxrscRphlVMkYdf~b9Obxz2plc3am58mLKxwJuwEgwdQ6R-C9s7MkU5xjJq1DQTuFHxKnMcLlgDEo7x2-yYizoMpRtTg15arGsIazk1~Aog2ZEhhbs7SFjLkUv9HgdXGcY5Af-4JHy615e~jazNKauz4biT4N9eOwAkGzA__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA)
