Health multilateralism in the Biden era: it is a change for the better, but is it a change for good?

R. Waldman

Ron Waldman President of Doctors of the World-USA

About six months have passed since the Biden Administration took the reins of government in the United States on 20 January 2021. It seems like a good time to take a look at what it has achieved in the area of global health. Ron Waldman, President of Doctors of the World-USA, leads us through this examination, which is as delicate as it is essential to appreciate the revival of multilateralism, so undermined under the Trump era.

President Biden inherited a chaotic situation characterised by the full-scale retreat from active and constructive engagement with the global community that had been engineered by the Trump Administration. The 46th President of the United States must be credited for acting swiftly and decisively to reverse what most practitioners considered to be a fairly long list of wrongheaded policies that had the potential to impact not only the global health architecture but even, sometimes directly, the health of individuals and communities around the world.

In this paper, I will review what has happened and, equally importantly, what has not, regarding US multilateral participation in three areas of global health during the first semester of 2021. These are engagement with international organisations and agreements, specifically with the World Health Organization (WHO); sexual and reproductive health issues; and refugees and migration. I will obviously evoke the Covid-19 pandemic which looms large over all aspects of global health and will have long-lasting implications on how US policies and activities evolve over the next decades. The issue of climate change should also be addressed, although the limited length of this article does not allow it to be discussed to the extent it deserves to be.

To begin, it is important to note that the American political environment remains extremely contentious. There is no agreement between the major parties on most political, social, and economic matters and there seems to be little potential for compromise on even relatively minor issues in the near future. While Democrats seem to be favourably inclined when it comes to international engagement in a variety of areas, albeit with significant reservations, Republicans have adopted, under the influence of former President Donald Trump, the “America First” approach that seeks to further American interests with little regard for the consequences this might have on both traditional allies (such as those within the Organisation of Economic Co-operation and Development) and on middle- and low-income countries around the world.

It is important to understand that isolationism and protectionism have been prominent populist themes running through American politics from the first days of US independence from Great Britain. The slogan “America First” was already used in the nineteenth century, but it was especially popularised during the early part of the twentieth century by President Woodrow Wilson in an attempt to keep the US from participating in the First World War(1)Interestingly, Wilson himself was very much in favour of international involvement and his espousal of “America First” policies was a calculated strategy intended to mollify the concerns of his political opponents. A similar approach of compromise in the name of bipartisanship seems to be very much part of the strategy of the current Administration.. Subsequently, it was adopted by isolationists seeking to block US involvement in World War II. At that time, fronted by the popular aviator Charles Lindbergh, the America First Committee continued to promote the idea, although its anti-war and isolationist orientation soon developed overtones of anti-Semitism, anti-immigration sentiment and sympathy for fascist ideology(2)“Germany and the America First movement”, Britannica, https://www.britannica.com/biography/Charles-Lindbergh/Germany-and-the-America-First-movement. Recently revived as part of Trump’s political platform during the 2016 election campaign and after his election, “America First” is a longstanding unilateralist tradition that, combined with intolerance, has always attracted a substantial part of the American electorate.

“Republicans have adopted, under the influence of former President Donald Trump, the ‘America First’ approach that seeks to further American interests with little regard for the consequences this might have on both traditional allies.”

When global health cooperation is resuscitated

Surprisingly to say the least, as the Covid-19 pandemic spread rapidly around the world, President Trump announced in May 2020 his intention to end US funding for the WHO and, more generally, all American participation in the organisation. If the reasons given were consistent with the philosophy of “America First”, this decision reflected it only in part, so much did it seem to draw on a deep animosity towards China. Trump claimed that China was not telling the truth about its knowledge of the origins of the SARS-CoV-2 pandemic, this “Chinese virus” in his own words, while he accused Beijing of exercising “total control over WHO(3)Elisabeth Mahase, “US to withdraw from WHO as China has ‘total control’ over it, Trump claims”, BMJ, 1 June 2020, https://www.bmj.com/content/369/bmj.m2178”. Yet the United States has long been the largest contributor to the organisation’s budget, providing approximately 400-500 million dollars annually, or 15% of the total budget and 22% of assessed contributions. As other major donors expressed support for the organisation, emphasising the essential role it played in coordinating the global response to the pandemic, the withdrawal of the United States risked dealing a fatal blow to its ability to carry out both its emergency control activities and its regular work programme.

On 7 July 2020, claiming that the WHO had failed to act to implement reforms demanded by his Administration, Trump followed through on his threat, sending a formal letter to the US Congress and to the United Nations (UN), announcing the US withdrawal from the UN’s health agency. However, US regulations stipulate that the US can only withdraw from a UN agency with one year’s notice. With Presidential elections looming in November 2020, Joseph Biden immediately announced: “On my first day as President, I will rejoin the WHO and restore our leadership on the world stage.” Indeed, just hours after his inauguration in January, Biden sent an official letter to the Secretary-General of the UN, reversing the planned pull-out from WHO and pledging to honour its financial commitment to the organisation.

At the seventy-fourth World Health Assembly in May 2021, Secretary of Health and Human Services Xavier Becerra, leading the US delegation, declared that “global collaboration will be key in tackling the many challenges still before us” and that “we will do this together with a strong and agile WHO(4)Xavier Becerra, “Secretary Becerra Delivers Remarks to the 74th World Health Assembly”, HHS, 25 May 2021, https://www.hhs.gov/about/news/2021/05/25/secretary-becerra-delivers-remarks-74th-world-health-assembly.html.” While it seems as if the US role in WHO will remain strong and contributory, and perhaps will be strengthened in the light of current circumstances, there apparently remains deep suspicion of China. This Administration has ordered the intelligence services to conduct an investigation into the origins of the pandemic, believing that WHO has not addressed this issue satisfactorily. The “lab leak hypothesis”, championed by Trump and his supporters in the US, has gained credence in the eyes of respected scientists and could become an increasingly serious point of contention in the coming months between the US and China. WHO risks being caught in the middle. Still, the fact that the US will remain, at least for now, a strong and influential member of the organisation and honour its current financial commitments, is a welcome development and a clear sign of renewed US commitment to multilateralism.

The US and vaccine equity

Launched in April 2020, the Covid-19 Global Vaccines Access Facility (COVAX) was organised by WHO, the Coalition for Epidemic Preparedness Innovations (CEPI) and GAVI, the Vaccine Alliance. Its goal is to ensure equitable distribution of effective vaccines by providing a mechanism for procurement and distribution of vaccines to countries that would have a difficult time competing for them in an open marketplace. COVAX hopes to provide enough vaccine doses to completely vaccinate 20% of the population in ninety-two countries. COVAX has enjoyed broad international support from the start and seems, to most experts, to be a practical way to speed the delivery of lifesaving vaccines to low- and middle-income countries. The US, under Trump, however, refused to join COVAX, with the White House reiterating that “we will not be constrained by multilateral organisations influenced by the corrupt World Health Organization and China(5)Emily Rauhala and Yasmeen Abutaleb, “U.S. says it won’t join WHO-linked effort to develop, distribute, coronavirus vaccine”, The Washington Post, 1 September 2020, https://www.washingtonpost.com/world/coronavirus-vaccine-trump/2020/09/01/b44b42be-e965-11ea-bf44-0d31c85838a5_story.html”.

At the same time, and thanks in part to Operation Warp Speed, a Trump initiative, two effective Covid-19 vaccines were approved for emergency use by the US Food and Drug Administration in December 2020, having been developed in record time. The US, and other wealthy countries that had entered into contractual arrangements with the pharmaceutical companies Pfizer and Moderna, the developers of the vaccines, were able to procure enough doses of protective vaccines for their populations, and in some cases for several multiples of their populations, as they became available. This practice led to a situation of gross maldistribution of an essential resource, or “common good”, and left many poor countries with no access at all. The phrase “vaccine nationalism” has come to describe a “me-first” approach to pandemic control that seemed to fly in the face of multilateralism and global health equity.

While the US had drawn up a plan to export vaccines to other countries around the world, Trump issued an executive order in December 2020 reaffirming the “America First” approach, stating that “Americans [will] receive priority access to the vaccines” before any are made available to others. However, on 19 February 2021, President Biden announced that the US would, in fact, reverse the decision of the Trump Administration and join the COVAX facility, pledging a donation of 4 billion dollars through 2022 to support its work(6)Anna Rouw et al., “COVAX and the United States”, KFF, 18 February 2021, https://www.kff.org/coronavirus-COVID-19/issue-brief/covax-and-the-united-states. On 9 June 2021, the US announced that it was entering into an agreement with Pfizer for the purchase of 500 million doses of its Covid vaccine. It will use 2 billion dollars of its pledge to COVAX as partial payment of the 3.5 billion cost of the vaccine, but all of the vaccines will be given to COVAX, which will be responsible for its distribution [Author’s note]..

Yet, despite this turnaround, and the announcement of a donation of eighty million doses of US-owned AstraZeneca vaccine that was not being used by the US, Biden also said, on 1 May 2021, that “[the US] will become an arsenal for vaccines for other countries, just as America is an arsenal for democracy for the world… [But] every American will have access before that.” This seemingly contradictory strategy, attempting to combine an “America First” approach with a recognition of global responsibility left many worrying that global vaccine equity would take a back seat to national self-interest and, consequently, seriously hinder the effort to control the pandemic in many countries.

As I write this [June 2021, Editor’s note], only four countries in Africa have vaccinated as much as 10% of their population with a single dose of Covid-19 vaccine(7)Statista, “Number of administered coronavirus (COVID-19) vaccine doses per 100 people in Africa as of June 10, 2021, by country”, https://www.statista.com/statistics/1221298/COVID-19-vaccination-rate-in-african-countries. Many high-priority individuals, including health workers, the elderly and those with underlying health conditions have not yet had access, while in the US more than half the population has received at least one dose of vaccine and about 40% are fully vaccinated. Children as young as 12 years old, a group generally considered to be low risk, are currently eligible to receive Covid-19 vaccines and the Biden Administration has pledged to vaccinate 70% of American adults with at least one dose by 4 July. This gross inequity between wealthy countries and those without the means to produce and/or procure an adequate supply of vaccine has led the Director-General of WHO to declare on 18 January 2021 that “the world is on the brink of a catastrophic moral failure – and the price of this failure will be paid with lives and livelihoods in the world’s poorest countries(8)WHO, “WHO Director-General’s opening remarks at 148th session of the Executive Board”, 18 January 2021, https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-148th-session-of-the-executive-board.” Notwithstanding this sentiment, it seems clear that the US, having done little to address global vaccine inequity during the Trump years, remains excessively committed to an “America First” approach in regard to Covid-19 vaccine distribution. It could do more to assure the equitable distribution of this game-changing tool. But it should be mentioned, breaking with many other wealthy countries and, to its great credit, the US has announced its support for a temporary waiver of intellectual property rights to the vaccines(9)Andrew Green, “US backs waiver for intellectual property rights for COVID-19 vaccine”, Devex, 6 May 2021, https://www.devex.com/news/us-backs-waiver-for-intellectual-property-rights-for-covid-19-vaccines-99847.

“The US, having done little to address global vaccine inequity during the Trump years, remains excessively committed to an ‘America First’ approach in regard to Covid-19 vaccine distribution.”

Climate change

Another aspect of multilateralism is agreement with and adherence to international treaties and covenants. The re-entry of the US to the Paris Agreement is another example of the shift that this Administration is making from previous policies. The Paris Agreement hopes to successfully address the other great existential threat to society, besides the pandemic, by addressing climate change and limiting the emission of greenhouse gases. Climate change certainly has major consequences for human, animal and planetary health, but space limitations preclude me from discussing these here. Suffice to say that Trump’s decision to withdraw from all aspects of the Paris Agreement (the only country to have done so) on the grounds that the US, the world’s greatest emitter of noxious gases, was being treated unfairly compared to China and India, had the potential to undermine a critical international treaty and further imperil the populations of many nations. The US rejoined the Agreement on 19 February and named John Kerry, an influential former presidential candidate, as its special envoy, a signal of the importance that it attaches both to the issue itself and to the multinational, cooperative manner by which it needs to be addressed(10)Helen Briggs, “What is the Paris climate agreement and why did the US rejoin?”, BBC News, 22 April 2021, https://www.bbc.com/news/science-environment-35073297.

Sexual and reproductive health

There is no more polarising and controversial issue in American politics than abortion. It has become a ritual for a Republican administration, on its first day in office, to institute the “Mexico City Policy”, also known as the “global gag rule”. This policy, from the time it was first formulated in 1984, has barred the granting of any US family planning funds to foreign NGOs that perform or promote any abortion services (including providing counselling that includes abortion as an option) as a means of family planning, regardless of the source of funding(11)American NGOs are similarly restricted through other legislation.. The Trump Administration vastly expanded this global gag rule by applying the same restrictions to foreign organisations receiving funding from PEPFAR (the President’s Emergency Plan for AIDS Relief), maternal and child health, malaria, nutrition and other foreign aid accounts. It is also part of the political ritual that a Democratic administration would rescind the policy during its first days. On 28 January 2021, Biden announced an end to the expanded rule(12)KFF, “The Mexico City Policy: An Explainer”, 28 January 2021, https://www.kff.org/global-health-policy/fact-sheet/mexico-city-policy-explainer. Nevertheless, the current Administration will have a battle on its hands in terms of maintaining a more liberal stance. Domestically, abortions rights are under siege and the Supreme Court, which has the final say on challenges to constitutional issues, is more conservative now than at any time in recent history. Indeed, the Court has recently declared that it would rule on a case that poses an important threat to the existing right to seek abortion in the US, as outlined in a landmark 1973 ruling known as Roe v. Wade. Should the right to choose be weakened or overthrown domestically, it is difficult to see how more liberal abortion-related policies would be allowed to remain as a part of US foreign assistance.

Immigration and asylum seeking

As mentioned above, the “America First” doctrine is associated with anti-immigration stances. During the Trump era, longstanding refugee policies were reversed – the US could no longer be seen as a country where the persecuted and oppressed could come to start a new, freer life. Annual refugee admissions declined each year and, by the end of fiscal year 2021, they were expected to be limited to 15,000, a record low(13)“Trump administration sets record low limit for new U.S. refugees”, Reuters, 28 October 2020, https://www.reuters.com/article/us-usa-immigration-refugees-idUSKBN27D1TS.

Although Biden had pledged during his campaign to raise the cap, he initially retained the Trump-era figure, only raising it to 62,500 after substantial backlash from members of his own party and from human rights groups. He also announced that the Obama-era ceiling of 125,000 annual admissions would be reinstituted during his second year in office, although it is not clear that the State Department will be able to process that many applications(14)“Biden backtracks on keeping Trump cap on refugees”, BBC News, 17 April 2021, https://www.bbc.com/news/world-us-canada-56778721.

Even more confusing, in this area, is the failure of the Biden Administration, in its first six months in office, to reverse the nonsensical invocation of Title 42 of the US Code to bar individuals from seeking asylum in order to enter the US, in accordance with Article 14(1) of the Universal Declaration of Human Rights. Title 42, adopted in 1944 and unchanged since, allows public health authorities “to prohibit, in whole or in part, the introduction of persons and property from such countries or places as he shall designate in order to avert such danger, and for such period of time as he may deem necessary(15)“42 U.S. Code § 265 – Suspension of entries and imports from designated places to prevent spread of communicable diseases”, Cornell Law School, https://www.law.cornell.edu/uscode/text/42/265.” In March 2020, the US Centers for Disease Control and Prevention, under political pressure and against the will of its scientists, issued an order under its Title 42 powers barring only one group of people – those crossing land borders with Mexico or Canada who might be held in detention by immigration authorities(16)Human Rights Watch, “Q&A: US Title 42 Policy to Expel Migrants at the Border”, 8 April 2021, https://www.hrw.org/news/2021/04/08/qa-us-title-42-policy-expel-migrants-border. Others, including returning American citizens and others crossing the border with valid visas including students and businesspeople, were not affected by the rule and could continue to enter the US. Obviously, from a public health standpoint, this makes no sense – the Covid virus does not infect people based on their legal status. Nevertheless, while pledging to ease the harsh restrictions and inhumane practices on the southern border that were commonplace during the Trump Administration, Biden has steadfastly refused to revoke the use of Title 42, in defiance of international human rights conventions to which the US is party. Since protecting the health of the US population is obviously not a concern here, it is difficult to explain this stance, but it seems to be based solely on political considerations, which makes it hardly compatible with a hoped-for return to multilateralism.

“The Biden approach, while tinged with elements of America First 2.0, is a welcome breath of fresh air compared to what came before it.”

In this article, I have tried to convey the message that a return to multilateralism seems to be an underlying principle of the Biden Administration’s approach to global health, although there does not yet seem to be a clear guiding strategy. Instead, half-way measures often seem to be taken with domestic political considerations at the forefront – the US will not leave the WHO, but it will conduct its own investigation into the pandemic origins; COVID vaccines will be purchased and donated to COVAX, but in insufficient quantity to allow COVAX to meet its goal, and too late to avert a heavy toll in the low- and middle-income countries that are now bearing the brunt of the pandemic; highly restrictive immigration policies will be somewhat eased, but unjustifiable policy remnants of the prior Administration will remain untouched. It might not be all one could hope for but, on the whole, the Biden approach, while tinged with elements of America First 2.0, is a welcome breath of fresh air compared to what came before it. Better, but not yet good enough.

Biography • Ron Waldman

A physician specialising in child health in developing countries and in humanitarian health in emergencies, Dr Ronald Waldman is President of Doctors of the World-USA and Professor Emeritus of Global Health at the Milken Institute School of Public Health of The George Washington University. He began his career with the World Health Organization’s (WHO) Global Smallpox Eradication Program in Bangladesh. He subsequently worked at the Centers for Disease Control and Prevention (CDC) for more than twenty years where, among other assignments, he directed technical support activities for Combating Childhood Communicable Diseases Project. In the 1980s and 1990s, he and his colleagues at the CDC published a series of studies on the epidemiology of refugee health and provided public health assistance in many international humanitarian crises. Ron Waldman was the coordinator of the Task Force on Cholera Control at WHO and the technical director of the USAID-funded child survival BASICS Project, and has worked in complex emergencies in Somalia, Rwanda, Bosnia, Albania, Democratic Republic of Congo, Afghanistan and Iraq, among others. He was the founder and former director of the Program on Forced Migration and Health at the Mailman School of Public Health of Columbia University. Dr Waldman received an MD from the University of Geneva and a Master’s in Public Health from Johns Hopkins University.

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References
1 Interestingly, Wilson himself was very much in favour of international involvement and his espousal of “America First” policies was a calculated strategy intended to mollify the concerns of his political opponents. A similar approach of compromise in the name of bipartisanship seems to be very much part of the strategy of the current Administration.
2 “Germany and the America First movement”, Britannica, https://www.britannica.com/biography/Charles-Lindbergh/Germany-and-the-America-First-movement
3 Elisabeth Mahase, “US to withdraw from WHO as China has ‘total control’ over it, Trump claims”, BMJ, 1 June 2020, https://www.bmj.com/content/369/bmj.m2178
4 Xavier Becerra, “Secretary Becerra Delivers Remarks to the 74th World Health Assembly”, HHS, 25 May 2021, https://www.hhs.gov/about/news/2021/05/25/secretary-becerra-delivers-remarks-74th-world-health-assembly.html
5 Emily Rauhala and Yasmeen Abutaleb, “U.S. says it won’t join WHO-linked effort to develop, distribute, coronavirus vaccine”, The Washington Post, 1 September 2020, https://www.washingtonpost.com/world/coronavirus-vaccine-trump/2020/09/01/b44b42be-e965-11ea-bf44-0d31c85838a5_story.html
6 Anna Rouw et al., “COVAX and the United States”, KFF, 18 February 2021, https://www.kff.org/coronavirus-COVID-19/issue-brief/covax-and-the-united-states. On 9 June 2021, the US announced that it was entering into an agreement with Pfizer for the purchase of 500 million doses of its Covid vaccine. It will use 2 billion dollars of its pledge to COVAX as partial payment of the 3.5 billion cost of the vaccine, but all of the vaccines will be given to COVAX, which will be responsible for its distribution [Author’s note].
7 Statista, “Number of administered coronavirus (COVID-19) vaccine doses per 100 people in Africa as of June 10, 2021, by country”, https://www.statista.com/statistics/1221298/COVID-19-vaccination-rate-in-african-countries
8 WHO, “WHO Director-General’s opening remarks at 148th session of the Executive Board”, 18 January 2021, https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-148th-session-of-the-executive-board
9 Andrew Green, “US backs waiver for intellectual property rights for COVID-19 vaccine”, Devex, 6 May 2021, https://www.devex.com/news/us-backs-waiver-for-intellectual-property-rights-for-covid-19-vaccines-99847
10 Helen Briggs, “What is the Paris climate agreement and why did the US rejoin?”, BBC News, 22 April 2021, https://www.bbc.com/news/science-environment-35073297
11 American NGOs are similarly restricted through other legislation.
12 KFF, “The Mexico City Policy: An Explainer”, 28 January 2021, https://www.kff.org/global-health-policy/fact-sheet/mexico-city-policy-explainer
13 “Trump administration sets record low limit for new U.S. refugees”, Reuters, 28 October 2020, https://www.reuters.com/article/us-usa-immigration-refugees-idUSKBN27D1TS
14 “Biden backtracks on keeping Trump cap on refugees”, BBC News, 17 April 2021, https://www.bbc.com/news/world-us-canada-56778721
15 “42 U.S. Code § 265 – Suspension of entries and imports from designated places to prevent spread of communicable diseases”, Cornell Law School, https://www.law.cornell.edu/uscode/text/42/265
16 Human Rights Watch, “Q&A: US Title 42 Policy to Expel Migrants at the Border”, 8 April 2021, https://www.hrw.org/news/2021/04/08/qa-us-title-42-policy-expel-migrants-border