The U.S. Congress Is Missing the Boat on Global Health Reform

There are no silver linings in pandemics, and there have been no bright spots in the dismal dysfunction of U.S. government action on the global fight against COVID-19 in recent weeks. First, the White House asked Congress for an absurdly low $5 billion for combating the virus beyond U.S. borders, and then even that paltry amount slipped out of reach at the end of March after members of Congress failed to come up with budgetary offsets to cover the global outlay.

Witnessing the U.S. government scrounge for change in other coffers to pay for investments in vaccine delivery systems, testing, and treatment, which are all essential for an effective, equitable global response—and then come up empty-handed—is a nadir, even in the context of the Biden administration’s dismally unambitious global response. But there is an opportunity to rise above this rock bottom of negligent necropolitics—if only the U.S. executive and legislative branches, as well as its lead agencies in public health, take action.

In March, the White House requested a total of $22.5 billion for domestic and global efforts against COVID-19 as a supplement to the fiscal year 2022 budget. Within that request, the White House sought just about $5 billion for the global COVID-19 response, in spite of prior acknowledgement that the need hovered around $17 billion for global action alone.

Congress accepted the request and then, after whittling the cost down to $15.6 billion, pulled it out of the budget bill after it became clear that the price tag would be met, in part, by unpopular offsets—pulling back unspent money allocated to states under the American Rescue Plan Act (ARPA). The global budget line had broad bipartisan support. Nevertheless, it was a casualty of the skirmish over the offsets. In late March, the Senate developed a stand-alone COVID-19 bill, once again covering both global and domestic spending. When the rummaging for offset funding came up about $5 billion short, the global budget line got pulled again.

Now Republican Sen. Mitt Romney is leading a negotiation process whose outcome is terrifyingly uncertain. A Senate-authored bill is expected to be released this week before the House recesses on Thursday. But in spite of advocacy from grassroots rabble-rousers to Bono, lawmakers have yet to take a firm, clear decision that the U.S. government should find and spend money for testing, treatment, and vaccination programs beyond its borders—even though such investments are crucial to an effective domestic epidemic response. As time runs out, the sums reported to be under discussion grow smaller. Under Romney’s watch, the budget line may have dwindled to as little as $1 billion.

That’s a lethal shortfall. In this apparent lull between variants, the wisest possible course of action is to build robust vaccination, testing, and treatment efforts overseas—using existing platforms such as the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)—and refuting the bizarre contention that people who have had COVID-19 and recovered do not need vaccines. People who’ve had COVID-19 and then get vaccinated have longer-lasting immunity than unvaccinated people who’ve had the disease or people who’ve been vaccinated but had no previous infection. If the U.S. government and the rest of the world want this lull to last, then they must invest in prevention and treatment now. It’s that simple.

So one crucial task for U.S. lawmakers this week is passing a COVID-19 funding bill that restores the full $5 billion for global work as a necessary if insufficient investment. But there’s more that Congress can do. Funding doesn’t matter unless it’s flowing through systems that work, and Congress can write legislation that supports an efficient, high-impact structure for U.S. efforts.

Just days before the supplemental COVID-19 budget request, the U.S. Agency for International Development (USAID) began to receive the first drafts of plans for 11 countries prioritized for “surge” support as part of the Initiative for Global Vaccine Access, or Global VAX, announced by USAID Administrator Samantha Power in early December.

On paper, Global VAX bears a striking resemblance to PEPFAR, the U.S. government’s most successful, longest-running pandemic-fighting effort. Launched in 2003, PEPFAR is managed by the State Department’s Office of the U.S. Global AIDS Coordinator and Health Diplomacy and implemented by a host of U.S. agencies, including USAID, the Centers for Disease Control and Prevention, the Defense Department, and the Peace Corps. In the field, U.S. ambassadors coordinate PEPFAR teams.

USAID’s Global VAX program is also designed as a whole-of-government approach and asserts that, as with PEPFAR, all agencies will be consulted and engaged in the planning process. In the early weeks after the 11 surge countries began their planning process, field staff offered mixed reviews of ground-level collaboration, transparency, and commitment to put funds where they are needed most versus where it is easiest to move the money—which is often to existing USAID grantees. Most worrisome of all, staff of PEPFAR programs described a planning and reporting process that is running in parallel to their own endeavor.

The decision to create new data dashboards, planning processes, and leadership structures for this phase of Global VAX is a perplexing one. All 11 of the tier-one countries preparing plans are also PEPFAR countries, yet the U.S. government is not spending its money via platforms with a proven track record of success. One explanation for this is that PEPFAR’s congressional supporters—a robust bipartisan contingent—are ever on guard for mission creep in the program, widely seen as President George W. Bush’s signature achievement. But putting money for the global COVID-19 response through parallel systems in PEPFAR countries—rather than using the same system for both programs—could hurt the program’s ability to perform even more, pulling human resources in multiple directions and increasing reporting and data collection burdens.

A neoliberal foreign aid program with plenty of flaws, PEPFAR is also highly effective and often deeply collaborative with communities overlooked or persecuted by their own governments. Over nearly two decades, the program has met increasingly high targets for providing lifesaving medications year after year. It has also already proved its worth in the new pandemic. The program received $250 million out of ARPA funds in fiscal year 2021, spending them swiftly on interventions to shore up HIV services and support COVID-19 responses.

And where PEPFAR doesn’t operate, the Global VAX structure could very work well. But if the primary object of Global VAX is to combat COVID-19 as efficiently and effectively as possible in PEPFAR countries, then the money should be offered directly to those countries. Some programs might not want the extra burden; others would welcome the chance to plan and report through existing systems.

One reason to build a separate platform is that it allows USAID to consolidate power and leadership in the U.S. government global health arena—which is, at the moment, very much in flux. In addition to the new Global VAX effort, the State Department is evaluating options for reorganization of its work on global health diplomacy and health security. Right now, the Office of the U.S. Global AIDS Coordinator and the Office of International Health and Biodefense are prime nexuses.

Conversations about the reorganization are in process, and the outcome is far from clear. But many infectious disease experts and activists are concerned about a scenario in which a new office or leadership role is created to oversee all of global health security and diplomacy. In the worst case, PEPFAR could become a program within a larger enterprise, and the U.S. global AIDS coordinator would be effectively a middle manager. On the other hand, the global AIDS coordinator could assume a dual-hatted role, ensuring that the platform is preserved and strengthened to fight AIDS and to respond to new pandemics. U.S. President Joe Biden has nominated John Nkengasong, a Cameroonian American virologist and current leader of the Africa Centres for Disease Control and Prevention, for the U.S. global AIDS coordinator role. If confirmed, he would be eminently qualified to originate and show the power of such a hybrid role.

Of course, without money, all of this is a moot point. The delay in securing funds for global COVID-19 efforts will cost lives. The least the U.S. government can do is to take a critical look at the structures needed to support a truly strategic, high-impact global health response to recent pandemics like COVID-19, established ones like HIV, and future threats that one hardly dares to imagine.

At present, Congress is the best hope for a different outcome. Ashish Jha, who will soon replace Jeffrey Zients as the White House COVID-19 czar, can help, too. Zients’ obfuscation on whether there are enough high-quality vaccines (there are not) or sufficient funding (there is not) has hurt the response for far too long.

Putting money in the bank for Nkengasong to spend if and when he assumes the global AIDS coordinator role would allow a seasoned leader the chance to tackle simultaneous pandemics in a region he knows incredibly well. This outcome wouldn’t be a bright spot, but it would be a glimmer—perhaps the light at the end of the tunnel.