Trump Is in a Coma on Public Health

On May 8, the minister of public health for the Democratic Republic of the Congo, Oly Ilunga Kalenga, announced that the Ebola virus had broken out in his country’s northern region, along the Congo River, setting in motion a rapid World Health Organization response. Ten days later, in a press conference at its Geneva headquarters, WHO concluded that the world’s efforts were already paying off and there was no need to formally declare a public health emergency of international concern, which would have activated the entire United Nations system. And history was made on Monday as the first person was immunized with a still experimental vaccine and for the first time as experts set out to stop an Ebola outbreak by vaccinating hundreds of people.

It’s heartening that so much has been achieved in so short a time — and startling that it all happened without leadership from the United States. The country is missing in action from this outbreak, with only a handful of Americans on the ground and no special funding from the Trump administration. That’s of a piece with how the U.S. government is increasingly withdrawing from global health efforts writ large. And the world has noticed. The governance of international health is already being organized in a manner less dependent on Americans — and less influenced by Washington.

Moreover, President Donald Trump recently asked Congress to rescind all special Ebola funding from the current federal budget and remove most of the financing for State Department emergency responses. House Speaker Paul Ryan signaled enthusiastic support for the budget cut requests, which are likely to be rubber-stamped by Congress. National Security Advisor John Bolton removed the National Security Council’s health security chief, Rear Adm. Timothy Ziemer, on the same day that the Ebola outbreak was declared, shutting down the entire epidemic prevention office. The move, which appears to have been part of a larger streamlining by Bolton of the entire NSC, leaves the United States with no clear line of authority for responding to any outbreak of disease, whether naturally arising or as an act of bioterrorism.

The Obama administration’s White House “Ebola czar,” Ronald Klain, who managed the response to the 2014 West African Ebola crisis, recently tweeted, “The world should watch to see if @USAID / @CDCgov play a major role in this response. If not, it represents a (sad) turning point in US leadership in global health.”

The U.S. Centers for Disease Control and Prevention says “about five” of its staff who are permanently based in Kinshasa, the capital, currently advise the Congolese government’s response and “some” more may be deployed to assist with laboratory work in the remote Bikoro area where the outbreak is unfolding. The CDC presence appears to be smaller than the team of seasoned Ebola fighters that arrived in Congo’s hard-hit area on Sunday from West African countries that faced the disease in 2014. The U.S. Agency for International Development on Friday promised $1 million to WHO for its Ebola efforts — far less than the $5.8 million promised by Germany.

To put this very modest engagement in perspective, in the 2014-2016 Ebola epidemic in Liberia, Sierra Leone, and Guinea, which ultimately claimed 11,300 lives, more than 3,700 Americans were on the ground — everyone from secretaries to top scientists rotating through the region over the course of the outbreak and the U.S. Army deployed for field hospital construction. It was the most massive overseas mobilization of personnel in the CDC’s history, with Congress ultimately approving $5.4 billion to underwrite the U.S. actions. The larger global effort cost about $4 billion, according to WHO Director-General Tedros Adhanom Ghebreyesus.

Global mobilization to the current outbreak is largely picking up where the last left off: Congo spotted the problem rapidly and immediately notified WHO; the health organization immediately deployed scientists and coordinated with other U.N. agencies and nongovernmental groups such as Médecins Sans Frontières; an air bridge, connecting the remote region to supply depots in Kinshasa, was created; and more than 4,000 doses of an experimental vaccine made by Merck were shipped to Congo. Perhaps most remarkably, Tedros personally visited Kinshasa and inspected operations in the field in Bikoro — the first director-general of WHO in its 70-year history to wade into an unfolding, highly lethal epidemic.

As of Friday, the Congolese government and WHO had identified 46 Ebola cases, slightly more than half of whom had reportedly died of the disease. According to Tedros, 99 percent of the cases are in the sparsely populated equatorial Bikoro area, where a loose network of villages is linked to a small government hospital and town by muddy footpaths. The region is only accessible by helicopter, there are no paved roads, and travel between its villages involves motorbikes and takes many hours, according to WHO officials. Nevertheless, by Sunday more than 100 responders from around the world were on the ground in the Bikoro area for the first mass vaccination in history to stop an Ebola epidemic. The Merck vaccine was field-tested in 2016 in the waning days of the West African epidemic, proving safe and effective, though neither the U.S. Food and Drug Administration nor any of its counterparts worldwide have yet approved the product.

As bold as this response may be, however, it is poorly funded. Only $8 million has been provided, with only Europeans — especially the United Kingdom’s foreign assistance program and Germany — having ponied up resources. Meanwhile, in the last three days a handful of cases have turned up in Mbandaka, a Congo River port city with a population of 1.2 million. There remains concern that Ebola could spread via Congo River trading to the capital of Kinshasa and abroad. Nine African nations are on alert, including neighboring Central African Republic, Republic of Congo, and Angola.

Yet the Trump administration has still remained silent. This perhaps shouldn’t come as surprise, given how Trump in 2014 famously tweeted opposition to rescuing Kent Brantly and other American health care workers who became infected in West Africa while volunteering to fight Ebola. Though Brantly then worked under Samaritan’s Purse, an organization co-created by Rev. Franklin Graham, now an ally to the president, then-businessman Trump attacked the group. He tweeted, “The U.S. cannot allow EBOLA infected people back. People that go to far away places to help out are great-but must suffer the consequences!”

Reid Wilson of The Hill recently reported that an Obama administration analysis by the White House’s Office of Digital Strategy identified Trump’s Ebola tweets as the pivotal moment when the tide of panic and fear soared inside the United States and millions of Americans demanded that epidemic volunteers and journalists be confined overseas or quarantined upon return to the United States. (I was placed in 21-day home quarantine when I came back from the epidemic in 2014, while no such cautions were taken when I returned from the 1995 outbreak in Kikwit, Zaire.) Amy Pope, who was then a senior counterterrorism official in the White House, told Reid: “It was that tweet that created a level of anxiety in the country. … That was a crystallizing moment.”

Bolton’s role as Trump’s national security advisor may come into play in the administration’s response to Congo’s outbreak, should it take an ominous turn. Long a vehement critic of the United Nations despite being a former U.N. ambassador, Bolton’s specific views of the organization and its agencies have long been clear. In a 2000 presentation to the conservative American Enterprise Institute, Bolton denounced the concept of “global governance,” which is a lynchpin of global health efforts. He decried what he termed “NGOs on Parade,” waging efforts to enhance the clout of ‘“civil society’ to participate in decision making on a level functionally equivalent to national governments.” And he denounced the 1981 WHO adoption of “a Code on the Marketing of Breast Milk Substitutes by a vote of 118-1, the Reagan administration casting the sole dissenting vote.” He concluded 18 years ago: “Whether we are ready or not, the debate over global governance, fought out at the confluence of constitutional theory and foreign policy, is the decisive issue facing the United States internationally.”

What’s clear is that as the United States recedes from the playing field, German Chancellor Angela Merkel is stepping up. She has been urging fellow Europeans to play a larger role, both with funding and political efforts. In 2017, Germany ranked No. 2 as a bilateral donor, after the United States, according to the Organization for Economic Cooperation and Development. It is the top donor to the WHO emergencies fund, which is now being drawn upon for the Congolese epidemic response, and pushed for the creation of the Coalition for Epidemic Preparedness Innovations, which funds vaccine invention to tackle outbreaks.

In April, Merkel, along with Norwegian Prime Minister Erna Solberg and Ghanaian President Nana Addo Dankwa Akufo-Addo, conveyed a powerful memorandum to Tedros, calling for a newly consolidated global health architecture that places WHO in leadership over all other health-related agencies, both within the U.N. system (such as UNICEF and UNAIDS) and outside multinationals (such as the World Bank and the Global Fund to Fight AIDS, Tuberculosis, and Malaria).

This is radical stuff: Only months ago, influential critics were declaring that WHO deserved to die or be stripped of most of its funding and mandates, in light of its Ebola failures — now, Merkel is pushing to give that institution primacy. Such a move would have both fiscal and political effects, because the WHO’s ultimate aim would be to build strong national public health and medical systems that would leave countries theoretically capable of fighting their own battles against disease. This is a scenario in which the United States, though still the country with the greatest resources, would not nearly be as indispensable globally.

Merkel and Bolton could hardly be further apart in their views on multilateral approaches to international health and development. If the current Ebola outbreak escapes its remote northern Congo confines, or another epidemic erupts elsewhere with the potential to reach the United States, the world will no doubt witness a sort of global health clash of civilizations, pitting Germany squarely against the United States.

As for Trump, who has still not appointed a White House science advisor and recently named a new CDC director who is well liked by anti-abortion conservatives, a newly leaked Bill Gates video and interview may, ominously, offer the most cogent insight. At two Trump Tower meetings, Gates urged the president to appoint a science advisor, to which Trump asked if the billionaire would take the job. Gates suggested that there were better uses of his time. Trump spoke of himself in the regal third person and twice asked what the difference was between the human papillomavirus (HPV, which causes cervical cancer) and the human immunodeficiency virus (HIV, the cause of AIDS) and expressed suspicion about vaccine safety.

If there is a serious pathogenic threat to the United States, the response will be driven by the national security advisor’s disdain for globalism and the president’s scientific ignorance, coupled with his refusal to turn to genuine expertise for guidance. Some Trump supporters may applaud saving a few million taxpayer dollars by cutting support of global health efforts and believe that other nations can, and should, handle outbreak threats. But America is a safer place precisely because of the depth of experience and wisdom its scientists and public servants have acquired from decades of engagement in health crises overseas.

Stepping away from such engagements only signals to the world that the United States no longer cares about the health and survival of non-Americans. Americans should not be surprised if, because of their government’s actions, the leaders of global public health organizations start to care less about them.