Cuts, Tariffs, and Tightening Borders – Trump’s United States and Global Health

Maggie Fox  00:01

Hello and welcome to One World, One Health, where we chat with people working to solve the biggest problems facing our world. I am Maggie Fox. This podcast is brought to you by the One Health Trust with bite-sized insights into ways to help address challenges, such as infectious diseases, climate change, and pollution. We take a One Health approach that recognizes that we are all in this together and everything on this planet — the animals, plants, people, and the climate and environment — are all linked.

The Trump administration’s sudden and ruthless slashing of the U.S. involvement in global health has been shocking. Nearly as soon as he took office, Trump said he would withdraw the United States from the World Health Organization (WHO), hitting funding used to fight malaria, tuberculosis, human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS), and a range of other diseases. Despite promises, the new administration has also dismantled the U.S. Agency for International Development (USAID), firing nearly all its staff and saying its work will be done through the State Department. The U.S. has now stopped funding the United Nations World Food Program — efforts to feed millions of people in 14 countries. The World Food Program says it’s a death sentence for millions of people. Funding has been cut to Gavi, the Vaccine Alliance, and other groups.

Until January, the U.S. was the single biggest funder of global health efforts. What does this sudden change mean for global health?

To try to see what the way forward might be. We’re chatting with Ramanan Laxminarayan, founder and president of the One Health Trust.

Ramanan, thanks so much for joining us.

Ramanan Laxminarayan  01:29

Well, thank you for having me back.

Maggie Fox  01:32

It’s clear now that USAID is gutted for the foreseeable future. Other than this, the foreign funding is virtually gone, too. And what else now? It’s hard to keep tabs on everything that’s gone.

Ramanan Laxminarayan  01:48

Well beyond USAID, we also have significant cuts at the U.S. Centers for Disease Control and Prevention (CDC), the last estimate is that of CDC has roughly 12,000 employees. About 4000 have been let go, which is a full third of the agency. The sexually transmitted disease (STD) lab was shut down completely a few days ago. The Chronic Disease sections of the CDC have all just been let go, which is a little hard to understand in a country with high rates of chronic disease and also some of the worst life expectancy per dollar spent anywhere on the planet.

So, for a country that doesn’t do so well on health, shutting down large parts of the public health system doesn’t make sense. There are knock-on effects. The CDC shutting down means that state health departments don’t have money. What a lot of people don’t realize is that much of the CDC’s money doesn’t sit in Atlanta. It goes out to health states, and in New Jersey, for instance, where I am today, the New Jersey Department of Health has layoffs because of CDC does not have the money to send to them.

That’s all and also separate from what’s happening with the National Institutes of Health (NIH), with the National Science Foundation (NSF), NIH particularly, is the if you might think of the nursery where, drugs and vaccines and diagnostics and you know future of medicine is born, and what happens there is what then comes out of the other end is products in about 20 years from now, and large parts of NIH are also under threat. So, all around it’s a time that will go down in history as a time when the U.S. health system and a research innovation system that was built over decades, if not centuries, have all been devastated in the space of just a few weeks.

Maggie Fox  03:32

And of course, this is not just devastating to the U.S., but it’s also devastating to the rest of the world. Global Health is going to have to look away from the U.S. for so much of this funding. Now, what does this mean for global health?

Ramanan Laxminarayan  03:46

Well, in the short term, the disruptions are going to be significant. In countries like Nigeria, for instance, which derives a lot of its health budget from U.S. government funds, it’s going to be a significant disruption.

20 percent of patients on antiretrovirals in South Africa depend on U.S. funding. It’s going to be disruptive for them. India, for instance, or China, is completely unaffected by what goes on in the U.S. concerning development assistance because they’re not recipients. I think in the short term, there will be a lot of difficulties that countries will have to come around to.

But I think in the medium and long term, the biggest losers in this shutdown is really going to be the U.S. itself, because, number one, it won’t have the engagement with science and technology and the soft power that it then enables in many of these countries. And number two, the U.S. does depend on the research and other countries to do things that would be simply too expensive to do here, for instance, CDC operates large facilities in Kenya and Thailand, which are sentinel sites for emerging pathogens in those places which are cheaper to understand there than if we were to have them enter the United States.

Not having that leverage is going to cost the U.S. a lot in the medium to long term. So, I think the damage to the rest of the world may be much less than we imagine in the medium term, where the world just figures out how to carry on without the United States. I think the United States is not irreplaceable. It’s important in the short term because of the role it has filled in the past, but I think that it’s important in a world, going forward, where you know it doesn’t want to engage is probably exaggerated.

Maggie Fox  05:26

So, where are countries and organizations going to turn to? How will they adjust?

Ramanan Laxminarayan  05:33

Well, you start with WHO, for instance — total funding for the WHO from the US government will probably be about 20 to 25 percent, probably closer to 20 percent, including voluntary contributions. I think that’s the kind of money that WHO, by improving its efficiency, which it will now be forced to do, can easily fill that gap.

It’s the U.S. again, which will feel the lack of not having an engagement with the WHO. In countries where drugs and vaccines are coming from, say, Gavi, The Vaccine Alliance or the Global Fund, or the United States President’s Emergency Plan for AIDS Relief (PEPFAR). I think now countries will have to be forced to step up. It will cause short-term disruptions, but I think in about three or four years, they will have figured out that this is something that they need to do, and it’s not something you can outsource to another country to fill that gap.

When I say the U.S., either it’s the U.S. or even philanthropy, in a sense, these are legitimate roles for government. Now these are all on the delivery side. On the innovation side, is where there will be the biggest challenge, because NIH does play a somewhat irreplaceable role in the world. NSF plays that kind of role as well, and here I am really at a loss to see where that innovation engine will come from.

The U.S. has a unique combination of both the money as well as the ecosystem that welcomes the best and brightest of people around the world through an open immigration policy, which then allows that magic of innovation to happen here in the United States — whether in technology or biomedical sciences or anything else you need those two you need the money and you need the bright people who are not necessarily going to come from within your borders.

By shutting down both at the same time, I think does irreparable damage, both to the United States, but also to innovation around the world, and that innovation will now move to places like China and India, where it’s already starting to happen, where there are large populations who are young, they don’t have the money just yet, but that will follow, if that’s where the innovation is starting to happen.

I mean, you keep in mind safer space, for instance, India routinely puts in interspace rockets that cost a fraction of what it costs in the United States. Or can we send a rover to Mars for less than it costs to make the film “The Martian”? So, I think a lot of this will now move to other countries, and again, the loss will be to the United States not to have the immigrants who do this work. And if you go to NIH, you’ll see, you know, many people that are European or they’re from other parts of the world, and that’s what makes these exciting places, because it’s like this Grand Central for ideas from around the world. And, you know, I would say, as an immigrant to the United States myself, that is really what this country made possible, and it’s now no longer seen as an attractive destination to come and play that role.

Maggie Fox  08:18

But is there another country that can become a central destination like that? What’s so special about NIH is that it’s a mixing bowl that also includes a lot of money. We’re talking a $48 billion budget that’s just been taken away, and that is not going to be easy to replace.

Ramanan Laxminarayan  08:39

Well, first of all, I don’t think NIH’s money is going to go away entirely. It may not be $48 billion. It may get cut a little bit, but I think that both are required. You need the money, and you need the talent, and it isn’t going to go to any one other country. It may go to multiple other countries, and the U.S. higher education system and research ecosystem are under serious threat.

And here again, it isn’t easy to just replace this in some other country. It took probably 200 years to build up the ecosystem that exists in this country right now. And it isn’t as if this is going to easily get replaced in some other country. It will take time.

But if you talk of a scale of, say, you know, 30, 40, 50 years, what has happened in the last two months has seriously shaken the confidence of people that the U.S. can be that haven for innovation, for biomedical research, for just creating things that it’s been for, for such a long time, — and confidence and trust you can only break once. If you break it one time, then, you know, people have a difficult time sort of, you know, imagining that it’s a safe place to come and do that sort of work again. Money is secondary to talent. I think the damage to immigration is understated. People don’t pay attention to that as much. But that is probably more important than the damage to the funding. Just waving a $5 million sort of gold card, or whatever it is that you know, this administration wants to have to give people, you know, a place in this country.

Rich people don’t build stuff. You know, it’s people who are hungry who want to create something. They’re at the other end — they can’t afford that kind of money, but they’re willing to work very hard and create amazing things that Take any amazing company in this country, they were all built in that sort of a way. So, I see the damage in both the money as well as the immigration.

Maggie Fox  10:27

So, what you’re saying is, you’re looking at the long term. Over the long term, the U.S. will be replaced. Do you think it’s a more disseminated type of thing?

Ramanan Laxminarayan  10:36

I think it already is affecting the willingness of students to come here. Why would anyone want to subject themselves to scrutiny at the border?

I mean, now even U.S. citizens entering the country are subject to secondary screening and all sorts of harassment at the border — forget about immigrants.

So, I think we’re going through a very, very dark time where, honestly, if I were a student coming in, this would not be my choice of country to come in, and it takes time to undo that damage. If you go to the U.S. Embassy website in New Delhi, which used to be a very friendly website, the website is now mostly threatening. It warns people about entering the U.S. illegally, which is like the primary messaging on the social media feed.

I mean, you must understand — it’s not like the rest of the world is somehow trying to enter the United States illegally all the time. It is a great country. But, you know, frankly, that’s not what people are trying to do. And if that’s the image that’s projected, which is very unfriendly, then that stays with people for a very, very long time. I don’t know if people who live in the U.S. already appreciate the kind of damage that’s being done, just in the face of the U.S. that is being shown on the outside.

Maggie Fox  11:53

In the short term, what do you see happening?

Ramanan Laxminarayan  11:56

Well, your guess is as good as mine, I think we’re being hit with a triple whammy if you might. The first is the destruction of the USAID infrastructure, which is the end of public health, which is delivering things to patients. So that’s being dismantled, which causes a lot of damage.

The second Level is destroying the research institutions and public health institutions, including the CDC, NIH, and NSF, which is the second tier of damage.

The third tier is the damage to the U.S. economy itself from the tariffs, which also causes significant damage. Why would you want to do business with the U.S. if there’s some crazy change in tariffs happening daily? The credibility of the U.S. is at serious risk, and what’s happening here is based on, and I think, as many economists have said, a very poor understanding of how the global economy works.

Nothing in the world is made in any country anymore. I mean, drugs, vaccines, and diagnostics, they’re all made in dozens – 20 to 30 countries. So, what does make in the U.S. even mean? I think that this idea that we can de-globalize and then suddenly we can start making, shoes here or I don’t know what it is that they plan to make here, but whatever that can be made here and then the rest of the world would want to buy it is, frankly, just lunacy.

As long as that myth stays, that this is somehow some future of the United States. We’re in for a very disruptive period of economic damage as well, which then, in some sense, eclipses the first two components I talked about. The $40 to 50 billion in USA funding is the amount that we’re bleeding on the stock market every microsecond. It’s trillions of dollars wiped out. So, or you know, even compared to the NIH funding, for instance. So, I think these three levels of damage work with each other. They are complementary to make things recovery that much more challenging. If we had only one or just two of the three, we could say, “Okay! We still have a strong economy. It’s fine!” Maybe not fine, but at least recoverable, but I think the scale of damage is at multiple levels.

Maggie Fox  14:06

One Health itself was just starting to come together as a vision. What’s the hope for the idea of One Health going forward?

Ramanan Laxminarayan  14:12

One health! Again, to back up, folks are listening to this, who are probably wondering what you know why One Health itself was relevant. One Health was relevant, because we went through an era where we thought we could control infectious diseases entirely through public health, water sanitation, and then following that with antibiotics and vaccines, and then we didn’t have to worry about infectious disease in a major way anymore, because we had sort of control over the pathogens that were going to hit us. And then we could move on to other things, and then we failed to realize that we’re changing the external world in multiple ways, through our use of antibiotics, especially in animals. We’re changing the world through climate change. We’re changing the world through impacts on air and water quality. Water through fertilizer use, air through just fossil fuel use, and, of course, deforestation.

So, in many ways, it wasn’t sufficient just to have good public health, water, sanitation, hygiene, and antibiotics. We then were facing a re-emergence of a lot of these health threats because we had failed to account for the other sorts of damage we were doing to the external world. So, it’s this idea that infectious diseases are all coming back in a major way, that is the idea behind One Health, in a sense, and that is not going to change. The next pandemic is not waiting for NIH to have money. It’s not waiting for the CDC to be ramped up. We already have H5N1- avian influenza, which is a serious threat. We have things like measles, which should not be a threat in the United States, coming back. I don’t think people even realize how deadly a disease Measles is, how rapidly it transmits, the damage that it does, and the immune amnesia that it results in.

I think that already, folks in the U.S. government are backing off from the anti-vaccine sort of stance. But I think if anything, the impetus for One Health is going to be even stronger, because One Health was about the stuff that we needed to fix, despite having good vaccines and everything else, and now you’re suddenly saying, “Wait a minute, I have all these new threats, but then all the other stuff that I already had going for me — like not having to worry about measles, is no longer reliable. I must worry about that as well.” It just means that we have a much bigger problem on our hands.

Gavi’s funding being threatened is a serious threat to the world, to children around the world, but also to the United States. So, I think, if anything, it will then come back to bite us as a much bigger crisis, and then maybe that will then promote reinvestment in health in a big way. Again, the U.S. has some of the worst health metrics for a wealthy country, despite spending a huge amount of money on health. The idea that this country, of all countries, can afford to cut back on public health or research is simply laughable. If anything, it should be spent far more on public health and research, not less. And maybe people have just forgotten that this is where their medicines come from when they have cancer, that’s the drug or the Chimeric antigen receptor (CAR) T-cell therapy, or whatever they are on started in NIH. They don’t see that connection right now, but I think that realization will come back, and I have no doubt that the U.S. will reinvest in health in a big way; it simply has no choice.

Maggie Fox  17:25

Ramanan, thank you so much for joining us.

Ramanan Laxminarayan  17:27

Well, thank you for having me.

Maggie Fox  17:30

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