What will a Trump Presidency Mean for Global Health Equity? [by Dr. Graham Lister]
Trump’s inauguration is an important moment for Medsin Members to consider what this presidency and Republican domination of the senate, congress and soon, supreme court may mean for global health equity. How might aid, trade and global governance of issues such as: human rights to health and protection from climate disruption? In this brief note I suggest some starting points for thinking through these issues and monitoring the threats to global health equity they represent.
The USA is the largest source of international aid, it provided $32 billion of $132 billion of total Official Development Assistance (ODA) in 2015, though this is one of the lower contributions as a percentage of Gross National Income (0.17% of GNI), it is also a major source of private and voluntary sector aid. This may be compared to the UN commitment made in 1970 to achieve aid flows of 1% of GNI (0.7% from ODA and 0.3% from other sources). The UK is one of 7 countries that meet this commitment to ODA. Trump and his team have offered few clues as to their attitude to aid, though he is on record as saying that “We should stop sending aid to countries that hate us”. The danger signs to look out for are clear from previous Republican administrations. During the last Bush presidency, US aid was increased from 0.11% to 0.21% of GNI (from 2001-2009), it has since declined to 0.17 % of GNI and Trump shows no sign of willingness to increase it. A central element of the Bush administration health aid was the Presidents Emergency Plan for Aids Relief (PEPFAR). While this continues to make a significant contribution, it has been criticised as placing too much emphasis on favoured countries and partners. Its “ABC” approach, emphasising, unproven “abstinence” and “be faithful” programmes with less emphasis on “use a condom” and no support for needle exchange programmes. US aid was also withheld from agencies offering guidance on abortion.
Trump policy on trade is clearer with commitments to withdraw from the Trans-Pacific Partnership, (TPP) which has not yet been agreed, renegotiate the North Atlantic Free Trade Agreement (NAFTA) and no doubt he would have withdrawn from the Transatlantic Trade and Investment Partnership (TTIP), had it not already been dead in the water. Advocates for global health equity have also challenged these deals because they give too much power to global corporations, encouraging a “race to the bottom” for health and safety protection. Trump’s opposition to globalisation is based on protectionism, presented as protection for US workers against low paid overseas workers but also protecting US global corporations from regulation in the interests of fair trade to promote global health and equity. This may result in global corporations (27% of which are based in USA) being given even more power to bully low income countries with the backing of US political power. Watch out for backtracking on unresolved issues health and TRIPS (Trade Related aspects of Intellectual Property Rights). Currently this World Trade Organization agreement that protects patents is mitigated to some extent by the 2001 Doha declaration which asserted that TRIPS should not prevent states from dealing with public health crises such as HIV/AIDS. But since Doha the USA and some other pharmaceutical producer nations have been working to minimize its effect.
An indication of the Trump and Republican attitude to human rights to health can be seen in opposition to “ObamaCare” (Patient Protection and Affordable Care Act) with plans already in place to defund, limit and replace it with some version of Health Savings Accounts. The question for health equity advocates is whether the denial of access to healthcare as a human right for some 20 million Americans is likely to influence attitudes to global health. More specifically the Republican focus on defunding women’s health and rights to health choices, services for the LGBT community and family planning are danger signs for global health equity.
Trump has tweeted “The concept of global warming was created by and for the Chinese in order to make U.S. manufacturing non-competitive.” Whether, in this post truth world, this is intended to be taken literally or not is not clear, but Trump has said it is not worth spending money on climate change and intends to withdraw from the Paris Climate Change Agreement. All those who are concerned at the threat climate change poses for global health equity and the lives of future generations and believe the overwhelming consensus of scientists and common sense observers will be horrified by this. Moreover, withdrawal from the Paris Agreement threatens the basis of global governance. How can a nation retract a carefully negotiated agreement at the whim of its ruler?
The challenge for Medsin is not simply to oppose Trump, it must be accepted that he is the elected leader of the world’s most powerful and influential country. It is therefore important to consider how the damage of his policies can be averted or mitigated and what role Medsin action can play. Trump does not enjoy the support of all Republicans, many have more balanced views, indeed he himself may be more sane than he appears. “You campaign in poetry. You govern in prose” or in his case perhaps “You campaign in tweets. You govern in mashups”. A lesson to be learnt is that Medsin must stress that global health is a local issue that affects everyone. At the same time advocacy in this country, Europe or at global fora must address the new reality (show) presented by Trump. During the last Republican presidency swift action was required to offset the withdrawal of USAID funding from family planning services that provided information on termination services. It now appears that global action will be required to mitigate the impact of many potential Trump policies.
If you are interested in global health diplomacy and advocacy you may like to flip through the materials where you will find the IFMSA course on this topic.