Argument

The Presidential Candidates Are Ignoring One of the World’s Biggest Looming Threats

Whoever sits in the White House come 2021 will likely have to confront a pandemic of some kind. He or she should start preparing now.

Members of the German military wait to have their suits decontaminated after a search for dead birds in northern Germany, where swans infected with bird flu were found, on Feb. 22, 2006.
Members of the German military wait to have their suits decontaminated after a search for dead birds in northern Germany, where swans infected with bird flu were found, on Feb. 22, 2006. Sean Gallup/Getty Images

Whoever sits in the Oval Office come January 2021, he or she will almost inevitably have to address pandemic disease as a foreign-policy issue. From AIDS and malaria to Ebola and pandemic flu, every president in recent decades has been faced with an international infectious disease outbreak that demanded both the attention of U.S. diplomats and officials and financing from U.S. budgets. Yet, to varying degrees, each administration has been caught unprepared. So far, the current set of presidential candidates does not seem more promising on this front.

The well-being of Americans in today’s globalized world is inextricably linked to that of people around the globe, while the effects of pandemics are born disproportionately by the least powerful. The next U.S. president needs a proactive strategic initiative, based in global solidarity, to address today’s pandemics, tomorrow’s outbreaks, and the health impacts of climate change.

U.S. presidents have a particularly powerful role when it comes to diseases that cross international borders. Barack Obama was initially criticized for a slow response to Ebola in West Africa, yet his decision to shift to a whole-of-government response and his address to the United Nations General Assembly meeting on Ebola were political watersheds that helped build the response that eventually ended the outbreak. Ronald Reagan’s failure to address HIV contributed to the pandemic we have today, and George W. Bush launched one of the most effective health aid programs in history with the President’s Emergency Plan for AIDS Relief (PEPFAR).

Even in a presidential campaign that has so far largely avoided foreign policy, the lack of attention to pandemics is notable. None of the leading campaigns (of either party) has come out with a foreign-policy approach that addresses global health. This is notable because pandemics are at the heart of the key issues that the Democratic candidates have focused on—pandemic disease burden makes economic inequality worse, not just by killing but by bankrupting families; LGBT people around the world are still disproportionately affected by pandemic diseases, including HIV; and the effects of climate change are felt in part through deaths from disease. Meanwhile, U.S. President Donald Trump’s administration has regularly proposed deep cuts to pandemic-related global health programs and has faced pushback from activists, public health leaders, and Congress.

The world needs more from the United States than, at best, avoidance of the issue and, at worst, the slashing of effective efforts.


Today, the second-largest Ebola outbreak in history rages in the Democratic Republic of the Congo. Health officials worry that Tanzania may be hiding evidence that the disease has also spread to Dar es Salaam, sparking a potential nightmare scenario. Ebola is just one of many infectious disease outbreaks around the world—outbreaks that have become significantly more common in recent years. A recent report from the Global Preparedness Monitoring Board found that there is a “very real threat” of a rapidly moving, highly lethal pandemic that could kill up to 80 million people and wipe out almost 5 percent of the world’s economy—a possibility that has grown with the speed of travel, globalization, and migration.

Meanwhile, as funding for global health stagnates, the fight against the world’s current biggest killers is faltering. The AIDS response, after decades of progress, is significantly off track from a global plan crafted just a few years ago. Some countries are making remarkable progress (in part with U.S. support), but worldwide there are too many new HIV infections and deaths in recent years to end AIDS, as promised. Gay men and transgender women worldwide, as well as young women in Africa, continue to bear the large part of the burden of HIV. At the same time, malaria cases are on the rise, and tuberculosis rates have barely budged. Together, these three diseases killed nearly 3 million people last year.

Climate change is already making things worse. Those with the least responsibility for global emissions are now facing not just rising sea levels but increasing spread of infectious diseases like dengue fever and malaria. A billion people could be newly put at risk as temperature changes extend the range and seasonality of mosquitos, according to one recent study. Flooding and destructive large storms are likewise increasing in frequency, and outbreaks of cholera and other infectious diseases often follow where health systems are weak.


The United States has a significant history of investing time and political attention on fighting diseases worldwide. Programs at the Centers for Disease Control and Prevention, State Department, and the U.S. Agency for International Development have been critical in tackling HIV, polio, tuberculosis, malaria, and a variety of other diseases. Where U.S. efforts have made a difference, the key has been high-level political commitment, sufficient funding, and a commitment to multilateralism. Although each of these pillars is today under threat, U.S. investments have built a platform from which a president could, if he or she chose, build a smarter and more coordinated whole-of-government effort.

Doing so would not only save lives but would also have benefits for broader U.S. foreign-policy goals. An analysis I and my colleagues recently published in the Journal of International Affairs showed that infectious diseases cost low- and middle-income countries—which include the world’s fasting-growing economies and key U.S. trading partners—$1.7 trillion in lost productivity. Meanwhile, investments to fight disease have an economic return of about $17 to $20 per $1 invested. A globally engaged U.S. foreign policy has to tackle economic prosperity, and fighting disease is an important tool on this front.

An approach built on solidarity with people around the world—one that recognizes and addresses global inequality and vulnerability—is necessary. Addressing pandemics effectively takes money and multilateralism.

The United States spends just 0.19 percent of its budget on pandemic-related global health spending, but world needs are growing along with the size of existing pandemics and the threat of new ones. The good news for political leaders is that polling by the Kaiser Family Foundation shows nearly 6 in 10 Americans say the United States should play at least a major role in improving health for people in developing countries. Countering populism with a realistic plan focused on specific goals that benefit health around the world, including in the United States, could be both good policy and good politics.

The United States could double spending on pandemic-related health efforts without breaking the bank because, in real terms, it represents a small cost for significant benefit. To start, the money could help increase the capacity of existing global health and diplomatic efforts. Bilateral programs like PEPFAR have seen flat funding despite a growing epidemic. The World Health Organization’s Contingency Fund for Emergencies has gone for years without sufficient funding because of a lack of political will from wealthy countries.

The Global Fund to Fight AIDS, Tuberculosis and Malaria just held its three-year conference of world donors last week and raised $14 billion. This includes increased funding pledged by the U.S. Congress, against the cuts proposed by the Trump administration, and every U.S. dollar will be matched by $2 from other donors. But far more is needed to get ahead of today’s pandemics. To prepare for the pandemics to come, an extra $4.5 billion per year is the gap estimated by the Commission on a Global Health Risk Framework for the Future. This would be a small investment compared with the potential return, and there could be real synergies if work to beef up laboratory capacity or the health workforce were aligned across AIDS, tuberculosis, malaria, global health security, and climate initiatives.

In addition, U.S. foreign-policy engagement could leverage action by others. One clear example is the Green Climate Fund, established by the United Nations to fund adaptation and mitigation in vulnerable communities. Even though the risk of disease linked to climate change is growing, the Green Climate Fund has so far invested little in health, which the United States could help shift. U.S. investments could also help build early warning systems, harnessing big data in weather and health, to predict where outbreaks will happen and then work with government and nongovernmental partners to mitigate the risk.

Meanwhile, in an era of populism, threats to international law trickle down to global health. Tanzania is resisting norms under international health regulations on sharing information about potential Ebola cases there. An engaged U.S. global health diplomacy effort on pandemics could shift the global politics.


Waiting to see whether the U.S. president will have to tackle a pandemic after the 2020 election is not responsible. We know the president will. How will he or she respond? Candidates’ answers to this question would reveal a lot about not just their views on international health issues but their views on the role of the United States in the world, inequality, and human rights. It’s time to hear those answers.

Matthew M. Kavanagh is a visiting professor of law at Georgetown University and the director of the Global Health Policy and Governance Initiative at the O’Neill Institute for National and Global Health Law.

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