Further Reflections on the US Return to Global Health

Following the inauguration of President Joe Biden and Vice President Kamala Harris on 20 January 2021, we have been treated to a lively first 10 days – announcing new directions on COVID-19, climate, racial equity, the economy, health care, immigration, and restoring America’s global standing.  While all these initiatives are very welcome, my focus here has been on the Biden Administration’s top domestic priority of controlling the pandemic – but from my usual global and multi-stakeholder perspective. And the good news on that score is that the US has returned to linking that domestic priority to active engagement in global health.  I shared my preliminary reflections on this good news last week (21 January 2021 and available here), and I have appreciated the lively reader comments and questions. Here is an update at the 10-day mark for the unfolding of the Biden Administration’s busy agenda on pandemic and health issues, along with my responses to the points raised by readers about the nature of US engagement globally and the prospects for a global response to the pandemic.

Returning to active engagement with the WHO

As reported in my earlier commentary, the announcement of a return to active engagement with the World Health Organization came in the form of a letter on the very day that President Biden was inaugurated, 20 January 2021. The letter from President Biden was sent both to the UN Secretary-General and to the WHO Director-General. And on the very next day, 21 January, it was followed up by the (4 am EST) Zoom appearance of Dr. Anthony Fauci at the (10 am CET) opening of the fourth day of the latest session of the WHO Executive Board.  This was as immediate as one could have hoped! The letter and Dr. Fauci’s appearance were then part of a broader policy change announcing the range of renewed engagement with the WHO and support to work with WHO member-states on reforms, as well as a commitment to join the COVAX Facility and a relaunching of a US-sponsored Global Health Security Agenda.

Dr. Fauci’s remarks were well received, and we all looked forward to the next steps confirming these announcements.  I was especially impressed that he included a reference to revoking the “Mexico City policy” in his opening remarks, and I start this update on that point. This leads to a more general observation about significance for global health of the domestic political scene in the US. I also share some thoughts about the need for American policy to accommodate the dramatic changes in the global environment this past year (and, of course, the past four years, too, for that matter). And I conclude with some comments about recent displays of vaccine nationalism in both the US and the European Union and what we can all be doing about this. I still believe the possibility is still there for a more global and multi-stakeholder response to the pandemic than we have seen so far.

The significance of the “gag” rule

First, it was encouraging that Dr. Fauci specifically mentioned the commitment by President Biden to revoke the “Mexico City policy” (also known as the “gag” rule), barring funds for programs that provided abortion services or even provided counseling for such services in developing countries. This policy was first invoked by President Reagan in 1984, then revoked by President Clinton; again invoked by President Bush, revoked by President Obama; and invoked yet again by President Trump, and now revoked by President Biden.  My kudos to Dr. Fauci for featuring this in his opening remarks and to link it to President Biden’s immediate agenda to embrace a “commitment to protect women’s health and advance gender equality at home and around the world.” I am happy to confirm that this was subsequently incorporated into a memorandum announcing actions to protect women’s health both at home and abroad, signed by the President on 27 January 2021 (available here).

US law still prohibits the use of American assistance to finance abortion services directly, something which was done years ago in the continuing struggle between pro-life and pro-choice coalitions, and this particular feature can only be changed legislatively through the US Congress. But the “gag” rule went well beyond this to bar funding of any reproductive health program overseas that provided abortion counseling or services even where American dollars were not used for that purpose.  Democratic presidents typically reversed the executive order, and Republican presidents typically reimposed the rule. In this latest seesaw on the order, President Trump had extended it to apply to all recipients of federal funds, even where they were not specifically providing reproductive health services. True to form, President Biden reversed the ban; and in so doing, his memorandum specifically mentions the need for American assistance to programs working on gender-based violence but also HIV/AIDS, tuberculosis and malaria, as well as the UN Population Fund. And of course, it also applies to WHO’s extensive work in this area, too.

To repeat the message even more clearly, the memorandum uses the specific language that has become integral to the global debate on abortion. That is to say, the US will once again be supporting “women’s health needs globally, including sexual and reproductive health and reproduction rights”.  Not only does this specific terminology apply, of course, to US support of the WHO, but it is an important shift for the US in other UN settings as well. This includes the forthcoming “Generation Equality Forum” (see more here) to be held in Mexico and in France to recognize and mobilize future action on the 25th anniversary of the Beijing Declaration and Programme for Action.  Thus, the change is far-reaching in enabling the US to be an important advocate for reproductive rights as an integral element for gender equality worldwide.

Nonetheless, the administrative nature of this action does raise the issue of American continuity, with a partisan see-saw wreaking havoc on globally funded programs whenever there is a change of political party in the White House. And on this issue, the continuing domestic debate on abortion rights is further aggravated by the four or five states that have recently enacted restrictions and the brewing prospects of a US Supreme Court reversal of Roe v. Wade.  This segues nicely into the broader point raised by many readers of my last commentary that US engagement needs to be different in tone and style from what it was in pre-Trump days.

Questioning The Long-Term Reliability of US Policy Changes

The uncertainty of the domestic political scene in the US raises concerns about the long-term reliability of US support for global health. We have all been subdued by the high voter turnout for the former president, and we have been further dismayed by the drawn-out challenges to the clearly legitimate outcome of the democratic process – and then shocked and horrified by witnessing the insurrection against the legislative branch instigated at a rally by a president still in office and legally bound to uphold the law. Even now, we might have had a week of euphoria that confirmed our “striving to forge a union with purpose”, as we reveled in the words of Amanda Gorman, the surprisingly charismatic young poet at the inauguration. (See her poem, “The Hill We Climb” here.) But the return to reality is setting in as we recognize (drawing from the words in her poem) that the “belly of the beast” is still among us, and that the “norms and notions “of the US Senate won’t necessarily give us the “just-ice” that we seek. When our allies around the world see this domestic turmoil, they have to wonder about the long-term certainty of relying on Biden administration policies. On matters like the “gag” rule, the challenge will be how to solidify the reversal so that it can survive a domestic political realignment in the future.

What is unfolding now, though, is more than a domestic uncertainty. Even as the world is welcoming the American return to multilateralism, there is the fact, as pointed out by several readers, that the world itself has changed. In the four years of the Trump nightmare domestically, the world changed in part because the US wasn’t there, but also because other parts of the world were changing in their own ways. I need not list too many of those changes here – the EU’s new leadership and clout, the Brexit debacle, the changing dynamics of French and German leadership, the emergence of China, new trade agreements with China in both Europe and Asia, the momentum on climate change, the emerging attention to biodiversity, the differential impact of social media and cyber security threats, the populist and jihadist movements around the world. Enough!

As far as the pandemic and global health issues are concerned, there is a need for the US to combine a readiness to treat the task of controlling the pandemic (and global health) as a global task with a big dose of humility about the kind of engagement that this readiness should embrace. One reader suggested that it should be a matter of “health first” and not “America first”. True, the latter slogan has already been repudiated, but another reader has a similar message. The US should not be expecting to “claim leadership straight away again” since others, and especially the EU, have worked hard these past four years “to keep global health going”.

In fact, various reform efforts – and emergency funding – at and with the WHO have already been underway, led by the European Commission, France and Germany.  They have been instrumental, too, in launching the Access to COVID-19 Tools Accelerator (ACT-Accelerator) initiative and in supporting the multi-stakeholder nature of this effort. Similarly, with the COVAX Facility for mobilizing resources for vaccine distribution in a global way, the basic concept has been to pool everyone’s resources for a global distribution of vaccines for up to 20 per cent of each country’s population, and this has come together without US leadership or engagement.

Implications of US Engagement with the COVAX Facility

As noted in my preliminary reflections on the US return to global health, Dr. Fauci did announce that the US would be joining the COVAX Facility and would support its work on the distribution of vaccines to developing countries. And this was confirmed in the details of the global health agenda announced by President Biden on the same day. (What is interesting to note, though, is that the US Congress had already appropriated $4 billion for the COVAX Facility, along with some $232 million for GAVI’s other regular vaccination services, in its second coronavirus relief package on 30 December 2020, even before President Biden was inaugurated. See the COVAX announcement here.)  Joining the COVAX Facility is, to be sure, a good thing, but I also noted (in my previous commentary) that this detailed announcement clarified that the US will only deliver a “sufficient surplus” of vaccines to the Facility once the US had met its own needs and then only to meet the needs of vaccine distribution to developing countries.

When I raised this concern to the panelists at a recent Zoom meeting of the Council on Foreign Relations, the panelist who responded (Rajeev Venkayya) referred to the $4 billion that had already been appropriated for the COVAX Facility as an important contribution because it would enable the Facility to buy vaccines on the global market. He added that the US was expecting to contribute another $10 billion to the Facility in the near future for that same purpose. I do, of course, accept the point that the $4 billion contribution is crucial, and I look forward to confirming that an additional $10 billion is in the works. In any case, this is a matter of the US throwing its money around without actually embracing a multilateral pooling of available vaccines. And instead of promoting a multilateral pooling, President Biden included in his announcements for a new comprehensive American pandemic strategy that the US had signed yet another advance purchase commitment for 200 million more doses (100 million each of the Pfizer and Moderna vaccines), bringing the US total to 600 million doses and enabling 300 million Americans to be vaccinated by mid-summer! That is to say, the US will now have acquired 600 million doses for domestic use and none for elsewhere.

This form of vaccine nationalism is disturbing, even where it is couched with sending money off to enable GAVI to go to the global marketplace for other vaccines. One line of defense is that the two available vaccines in the US basket are just too difficult to administer in developing countries, with the rationalization that it would be better for developing countries to wait for more manageable vaccines in the pipeline (such as the AstraZeneca or J&J or Novavax vaccines) that may take longer to be approved but are cheaper or single dose or requiring less cold refrigeration.  A counter to this argument is that most developing countries are way ahead of either the US or Europe in pandemic preparedness to distribute vaccines, but they have been cut out of having any access to any immediate supply of available vaccines by these prior commitments to rich countries’ advance purchase agreements. Another line of defense is that the US is only now joining in the global response and that every one of the other major players in the COVAX Facility have already done their own separate deals. Canada bought up five more times the quantity that it needed for its own population; Israel paid top dollar to get early deliveries; the UK made its own deals with Pfizer, Moderna and AstraZeneca; and the European Commission is going berserk that its own advance purchase agreements are not getting timely deliveries from either Pfizer and AstraZeneca because of logistical difficulties in their designated manufacturing facilities.

The Low Point of Vaccine Nationalism

The latest spat between the European Commission and the UK is especially revealing. The EU wanted AstraZeneca to ship them vaccines from their manufacturing facilities in the UK, while the UK was insisting that the EU should wait for the company’s European manufacturing plants to get up to speed. The EU is arguing not fair, despite the fact that the EU’s agreement with AstraZeneca was signed months later than the UK’s agreement. Contract terms, which are normally confidential, have been publicized in this case – showing thereby how different negotiators have been getting different prices and liability terms for the same products. And the Commission escalated the spat with plans to restrict exports of Pfizer vaccines from manufacturing facilities in Europe to meet the UK’s orders – or the orders of any of another 100 countries – in retaliation.  This is vaccine nationalism with an additional twist of closing down the free trade in vaccines, much as it had been threatened earlier in the pandemic over facemasks and personal protective equipment.

This latest move merits two additional observations from my modest multi-stakeholder perspective. First, I fully understand the pressure on the EU to keep its 27 member states happy. It is a new effort for the EU to manage what has otherwise been a state-level responsibility, and it took a lot of persuading to get the likes of France, Germany, Italy and Spain to back off from doing their own deals with vaccine manufacturers. The EU’s deals were understandably later than most of the others among the rich countries – as a result of the delay in clearance but also a new learning curve. So now the EU needs to prove it was worthwhile to collaborate – even when the renegade Hungary goes off and buys its own stock of Chinese and Russian vaccines! And Spain had to close down its vaccination campaign for lack of EU-supplied vaccines. And France regretted its own vaccine development setbacks. Nonetheless, the fluidity of the situation is illustrated by the way that the  different manufacturers are scrambling to announce additional deliveries to ameliorate the shortfalls, thereby reinforcing the advantage of EU-level negotiating strength. Anyway, this is an ever changing scenario, and I understand the pressure.

Second, I do find it interesting that the EU effort to restrict exports specifically excluded the 92 developing countries who are the regular recipient countries of GAVI, the Vaccine Alliance. This is consistent with previous announcements from the European Commission that the consolidated EU approach to vaccine distribution should include provisions for sharing their purchases with developing countries, presumably through the COVAX Facility. That is to say, the EC was justifying the application of its negotiating power to negotiate a reduced price with vaccine manufacturers for distribution both to its own EU member states but also to developing countries, presumably including 92 developing countries that constituted the regular membership of GAVI, the Vaccine Alliance. Although it’s not clear when this distribution was actually going to happen, given the domestic pressures within EU member states, it is at least a sign of European willingness to operate globally. Of course, it still does not apply to the idea that COVAX could also deliver a vaccine pool for a more truly global distribution that included all countries, whether they are rich or low and middle income countries.

Vaccines for Everyone

One concluding point here is to focus on the need to mobilize support for the multilateral benefit of a COVAX Facility for everyone. This isn’t a matter of vaccine nationalism being detrimental only to low and middle income countries. The International Chamber of Commerce has recently published a study (available here) on the massive economic damage of vaccine nationalism, documenting the direct cost to the advanced economies themselves as well as the world generally. Both the WHO Director-General and the UN Secretary-General have drawn on this study to reinforce their pleas for prioritizing the most vulnerable wherever they might be. Even the currently leaderless World Trade Organization has protested the scourge of vaccine nationalism, with its four Deputy Directors-General calling upon the WTO’s members to work together to ensure worldwide access and universal coverage (WTO news release here). And take note, too, of the latest recommendations (available here) from the leading candidate to head the WTO, Ngozi Okonjo-Iweala, who has spoken up for active use of existing WTO flexibilities to combat the protectionist momentum.

I am hopeful but not optimistic that the US will do much more than throw some more money in the direction of the WHO or the COVAX Facility – or that the European Commission will do more than reaffirm its commitment to help with negotiating a lower price for whatever the COVAX Facility can acquire for distribution to low and middle income countries. That is to say, neither seems ready to embrace the global pooling and prioritizing of available vaccines for everyone that I was hoping to see. And maybe the whole system is flawed.

Critics of the ACT-Accelerator and COVAX have been claiming that the whole effort there is biased against developing countries and even against civil society. Many representatives of developing countries have been calling for a different approach, both at the World Health Organization, through a Technology Access Pool, and at the World Trade Organization, through a waiver of intellectual property rules. Even the head of UNAIDS, Winnie Byanyima, has called for “a #People’sVaccine, not a profit vaccine” (available here), and several major NGOs have joined together in a Peoples Vaccine Alliance. (See their new website here, subsidized by Oxfam.)

I will continue to urge the Biden Administration to join the COVAX Facility, both for helping other countries and for helping the US to be a part of a global pooling of future vaccine distribution. I hope the European Union will also embrace both aspects of this Facility. Active engagement with interested parties at the WHO should also move forward on reforming the financing and political framework of this UN agency, with the understanding that any significant increase in the assessment of members’ dues should factor in the rest of the UN system’s assessment methodologies as well. This is, to be sure, quite another topic for a future commentary! Similarly, the whole idea of multi-stakeholderism at the WHO and in its pandemic preparedness (including the International Health Regulations) will merit a future commentary. And then, there is the matter of the WTO. As you may have seen from another of my earlier commentaries (available here) on the WTO, I am a strong supporter of Ngozi Okonjo-Iweala to head the WTO and hope that the US will come around to her support soon.

NOTE on Sources:

The fluidity in the present state of vaccine availability is only one part of the uncertainty today. Several readers asked for information on status of vaccine development and on who has ordered which quantities of available vaccines. I find it useful to rely on various tracking systems and to check in on what the WHO and the COVAX Facility are doing, especially the regular pandemic media briefings by the WHO. I suppose the new pandemic briefings by the US team will also be useful. The coronavirus itself is undergoing changes, too, with new variants that may require new or updated vaccines but further reinforce the urgency of comprehensive diligence. New developments on testing and therapeutics and an improving understanding of effective prevention are all contributing to the changing dynamics. Here is my working list:

Duke Global Health Innovation Center has a Launch and Scale Speedometer that tracks both vaccine development and vaccine manufacturing output: https://launchandscalefaster.org/COVID-19#Interactive%20tables%20and%20charts%20-%20COVID-19%20Vaccine%20Advance%20Market%20Commitments

Milken Institute Vaccine Tracker:  https://www.covid-19vaccinetracker.org/

New York Times tracking of vaccine developments:  https://www.nytimes.com/interactive/2020/science/coronavirus-vaccine-tracker.html

WHO Landscape of COVID-19 Candidate Vaccines: https://www.who.int/publications/m/item/draft-landscape-of-covid-19-candidate-vaccines

WHO COVID-19 Press Briefings: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/media-resources/press-briefings

Thanks for all of your comments, and please continue to share them with me. As Captain Sir Thomas More said when approaching his 100th birthday, it is never too late to make a difference! Rest in peace, Captain Tom!

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