The authors of this collection consider the most pressing foreign policy challenges for the next US president, and examine how the outcome of the 2020 election will affect these. 

The president will determine how the US’s diplomatic, economic and military resources are invested, and what value the administration will attach to existing alliances and multilateral institutions. 

Whoever sits in the White House will shape the trajectory of the US–China relationship and the global economy after the COVID-19 pandemic, as well as international cooperation on climate action, international trade and technology policy, and health.

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07 The US and global health security

By re-engaging in multilateral cooperation on global health security, the US can better protect its own citizens and economy, and build up capacity to withstand the next public health emergency.

The COVID-19 pandemic has given rise to the worst public health crisis in a generation. In the US alone, some 7.7 million cases had been confirmed by mid-October 2020, and more than 213,000 deaths.119 Globally, there have been infections in nearly every country, with cases already numbering some 38 million. The virus has changed the way people live, work, travel, and supply goods, and will have far-reaching consequences for years to come. There has been no issue that has more dramatically affected the course of the Trump presidency, and no issue that has so clearly highlighted the negative impact of the US’s return to isolationism over the last four years.

The possibility of a severe pandemic with far-reaching health, social and economic consequences has long been predicted.120 Over the last two decades, there have been a range of infectious disease threats – from H1N1, H5N1, and H7N9 influenza to the emergence of Severe Acute Respiratory Syndrome (SARS) and Middle East respiratory syndrome (MERS). The 2014–16 West African Ebola epidemic was the largest Ebola outbreak ever recorded. And in 2016 the World Health Organization (WHO) declared a Public Health Emergency of International Concern after a widespread epidemic of Zika fever, caused by a mosquito-borne virus, revealed an association between infection in pregnant women and clusters of microcephaly and other neurological disorders in their infants.

A pandemic caused by a respiratory pathogen has been the main focus of pandemic preparedness efforts. The evidence suggested that the costs of a highly contagious respiratory illness would be inevitable and devastating. SARS, for example, had been estimated to have cost the world well over $30 billion.121 More importantly, recent outbreaks of various kinds had highlighted key deficiencies in the abilities of countries to quickly contain an infectious disease outbreak. Despite the warnings of experts for the last several decades, and the implementation of programmes designed to strengthen preparedness and response capacities across the world, several assessments had judged that much of the world remained unprepared to respond adequately to a pandemic.122

In the US, President Trump’s response to the pandemic, and its impact both at home and across the world, has veered between hubris, denial and the shifting of responsibility. This has left constituents and partners confused and disappointed. Not only has the US stepped back from the global leadership role it has typically played in the post-war era; it has undermined its own credibility by failing to manage an effective response to the spread of infection within its own borders.

Without a significant shift in direction in tackling the far-reaching consequences of COVID-19, the US risks permanently losing its capacity to act effectively as a global leader.

There are no grounds for optimism that the coronavirus pandemic will be contained by the time the next administration takes office, in January 2021. The US has already squandered much of the goodwill it had with partner countries on any number of issues over the last four years; and now, without a significant shift in direction in tackling the far-reaching consequences of COVID-19, the US risks permanently losing its capacity to act effectively as a global leader. These consequences are not limited to its ability to build up its own resilience to the next pandemic – although in the age of mass travel, global supply chains and rapid urbanization that is certainly a major risk. What the present pandemic has underscored is that the stress on many already impoverished communities will likely impact governance and regional stability, and trigger new waves of migration, extremism and violence, all of which will have consequences for the US. Furthermore, the Trump administration’s handling of the coronavirus, and its lack of regard for neighbouring countries in their own efforts to fight the spread of infection and mitigate the impacts of the virus, could prolong the outbreak and cause even greater harm to people and economies globally, thus compounding the damage the US has already inflicted on itself.

The US’s global health leadership role, pre-Trump and pre-COVID

The US has contributed to international action on global health over many decades, and across both Republican and Democratic administrations. The US was a founding member of WHO in 1948, and while there has always been some tension between national and multilateral interests, the last two decades have witnessed a sustained commitment to US global leadership on this issue. In 1999, the Clinton administration’s National Security Strategy equated international epidemics with war or terrorist acts as threats to human life, and recognized that ‘the resulting burden on health systems can undermine hard-won advances in economic and social development and contribute to the failure of fledgling democracies’.123 ‘The international community is at times reluctant to act without American leadership’, the report stated. ‘In some instances, the United States is the only nation capable of providing the necessary leadership and capabilities for an international response to shared challenges.124

The 9/11 attacks on the US mainland, and the anthrax attacks that followed soon after in the autumn of 2001, brought urgent scrutiny of the US’s potential vulnerability to extreme shocks, including not just terrorism and bioterrorism, but biological threats such as an infectious disease pandemic.

Under the presidency of George W. Bush, the US remained committed to its responsibility to engage at the multilateral level on global health. In the wake of the SARS epidemic in 2002–03, for instance, the US participated actively in WHO’s work to revise the International Health Regulations (IHR 2005), the binding international legal framework to guide countries in preventing, protecting against, controlling and responding to public health risks. Most significantly, through the President’s Emergency Plan for AIDS Relief (PEPFAR), instituted in 2003, the US made the ‘largest commitment by any nation to combat a single disease in human history’.125 President Bush sought relatively significant resources from Congress, amounting to $15 billion over five years, embracing this action as being in the country’s ‘moral, practical, and national security’ interests.126

The 9/11 attacks on the US mainland, and the anthrax attacks that followed soon after in the autumn of 2001, brought urgent scrutiny of the US’s potential vulnerability to extreme shocks, including not just terrorism and bioterrorism, but biological threats such as an infectious disease pandemic. In 2005 the federal government drafted the first National Strategy for Pandemic Influenza;127 and in 2008 the Biomedical Advanced Research and Development Authority (BARDA) was established, within the Department of Health and Human Services, with a mission to develop vaccines for unanticipated infectious diseases.128

In 2009, within months of taking office, the Obama administration was confronted with the H1N1 pandemic, which infected more than 60 million Americans in the course of a year.129 As well as managing the domestic response, the US worked with WHO, and through the organization’s intergovernmental processes, to mitigate the global impact of the pandemic. Through this cooperation, the US contributed substantively to the development of guidance on surveillance and the use of antiviral drugs, and of the pandemic influenza preparedness framework for the distribution of vaccines.

Building on lessons learned from H1N1 and other infectious disease outbreaks, and recognizing that it was in the US’s interest to increase the health capacity of its global partners, in 2014 the Obama administration launched the Global Health Security Agenda (GHSA).130 As part of the GHSA, participating countries identify metrics for assessing the capacity of countries to respond to public health challenges, independently assess them through the joint external evaluation process, then tailor assistance plans to increase that capacity. The initiative was not wholly altruistic. Underlying the US’s financial and resource commitment was a recognition that if an infectious disease overwhelms the response capacity of the country in which it originates, it could quickly spread and destabilize others in a region – and perhaps globally.

These principles were tested by the 2014–16 Ebola outbreak in West Africa. Although only a small number of cases were recorded in the US, that they occurred at all revealed gaps in infection control, border controls, public health connectivity and resourcing to manage the outbreak. The US response – to significantly increase support to West African countries, and to partner with the UK and France, among others, on a comprehensive response strategy – was an investment not just in the region, but in US public health.131 There was a consensus, since borne out by the experience of the current COVID-19 pandemic, that once there is community transmission of a virus in any US urban area, the ability to quickly contain it – and to minimize public and political anxiety – reduces dramatically. Following the Ebola outbreak, the Obama administration documented these lessons learned in multiple after-action reports, by drafting a detailed early-response ‘playbook’, and by establishing a National Security Council directorate within the White House, with a primary mission to identify and mitigate possible new infectious disease threats.132 By bringing high-level political attention to this issue, the goal was to increase support for the strongest possible response in the event of the next outbreak.

The common thread running through these prior administrations, therefore, was the understanding that infectious disease response was apolitical; that it was the responsibility of the federal government to build on the lessons learned from past outbreaks in order to improve response to the next; and that a public health threat such as a catastrophic infectious disease outbreak could be as destabilizing to US national security as a terrorist attack.

Despite the recognition that the US could not effectively control a global infectious disease outbreak on its own, and notwithstanding considerable investments in improving preparedness and response capacity, neither the Bush nor the Obama administration left office having built up sufficient resources and political will to ensure the response capabilities needed to effectively manage a pandemic like COVID-19. While the post-9/11 anthrax attacks, SARS in 2009–10 and Ebola in 2014–16 accelerated investment in infectious disease response, this capability remained relatively weak and fractured in comparison with US investment in ‘traditional’ counterterrorism measures over the same period.

Thus, while countless officials agreed on the need for greater coordination and investment, there remained significant gaps in the US’s ability to manage an outbreak on the scale now seen with the coronavirus pandemic. This was particularly the case with regard to funding, even after a significant injection of resources as part of an Ebola supplemental. Furthermore, the realization that infectious disease response needed to be major part of the national security apparatus still had not taken hold across the federal bureaucracy. The Obama administration took steps to change that perception, but it was anticipated that the successor administration would need to continue to build on this foundational work if the US was to have the capacity to withstand the next major infectious disease outbreak.

The US response to COVID-19

As has been clearly seen in its handling of the current pandemic, the Trump administration failed to draw on the lessons of the recent past. The response of the US government to COVID-19 has, moreover, been unprecedented in its politicization, and in its role in heightening the confusion and tensions around the disease. At every turn – from dismantling the National Security Council directorate, to marginalizing the US Centers for Disease Control and Prevention (CDC) and publicly disparaging key public health leaders, to offering confusing and conflicting guidance on infection-control procedures – the current US administration has failed to demonstrate effective leadership.133

At global level, the US has declined to take a leading role in the collective effort to fight COVID-19. At times, too, the Trump administration’s interventions have been antagonistic and counterproductive. Nowhere has this been more striking than in its response to China. While there are legitimate questions about the Chinese government’s early reporting of the outbreak, including whether it was fully transparent and timely in transmitting information about the impact, scope and origins of the outbreak, Trump’s personal response has been to vilify and alienate the Chinese government. Even before the pandemic, he withdrew CDC staff from the country, and cut funding for research collaboration with researchers in Wuhan, hamstringing its best sources of intelligence and mitigation.134

The US appears to have turned its back on its international partners, too, as signalled not least through its efforts to buy up the world’s supply of remdesivir and its suggestion that it will not partner internationally on vaccine distribution. This isolationist response to the pandemic, also evident in its conspicuous absence from the Access to COVID-19 Tools ACT-Accelerator – a multinational collaboration between public and private institutions, launched in April 2020, to expedite the development, production and provision of fair access to COVID-19 diagnostics, therapeutics and vaccines135 – doesn’t just cause resentment among the US’s long-time allies. It also crucially fails to acknowledge the US’s own dependence on the success of a global endeavour to counter the transnational threat from COVID-19.

Of even greater concern is the Trump administration’s formal instigation, in July 2020, of the process of withdrawing the US from WHO.136 The US is at present the biggest donor to WHO – providing about 15 per cent of the organization’s total budget – and has contributed to major initiatives including the agency’s emergency health operations.137 In isolation, the US itself does not have the capability or the reach that would allow it to unilaterally monitor emerging infectious diseases, or to influence their management, yet COVID-19 has shown, on a shocking scale, how susceptible US public health is to the spread of infectious diseases originating beyond its borders. Withdrawing from WHO, even if legally possible, without offering a meaningful alternative to coordinate global efforts to tackle infectious diseases leaves the US considerably more vulnerable with regard to this outbreak and the attendant consequences.138

The global health agenda for the next administration

If there is a Biden administration, it will take office likely while the country is still in the throes of managing the response to COVID-19. There will be immediate opportunities for leadership, both domestically in getting the virus under control in the US, and in global stewardship of mitigation efforts. Both scenarios could bring into stark relief the longer-term impacts of neglecting under-resourced communities and countries in terms of fostering sustainable economic and global stability.

It will not be enough for the next administration to recommit to the baseline standards of its predecessors. Too much valuable ground has already been lost. To avoid further harm to US economic and public health, the next president must not only re-establish its starting position at the end of the Obama administration, but also look for opportunities to lead in building a comprehensive global response to the pandemic – and to shore up its position for the next pandemic, when it inevitably comes.

Leading a coalition of willing and well-funded partners, in the public and private sectors, to mitigate the impact of COVID-19 is key to US recovery.

In the first instance, the administration must significantly increase funding and political prioritization of its domestic and global health response to COVID-19. The US ultimately relies on a global economy. Even if the virus is contained in the US, if it is still raging in key supplier markets, and if travel remains severely disrupted, the US economy will continue to suffer. Furthermore, the social and economic impacts of COVID-19 could further destabilize more vulnerable countries, leading to increased migration, extremism, hunger and corruption. Leading a coalition of willing and well-funded partners, in the public and private sectors, to mitigate the impact of the disease is key to the US recovery. The US should not only invest in the ACT-Accelerator; it needs to become a leader in this public-private partner effort. Both as part of the accelerator and multilaterally, it should work with partners on protocols around resuming international travel and appropriate border controls, building best practices for testing and tracing new outbreaks, and for distribution of key supplies, medical counter-measures and vaccines.

Second, the president must recommit to US investment in the key multilateral organizations – including WHO – so that it is better prepared for the next outbreak. The administration should ensure that there is an unflinching assessment of key lessons learned; but the answer is to reform, not to walk away. The US must ensure that its seat on the WHO executive board is not only swiftly filled, but filled by someone with suitable credibility and expertise. It should marshal like-minded countries to evaluate whether the WHO reforms of recent years have gone far enough. It should work to ensure WHO has the authority and the resources that mean that the organization has sufficient independence to act in the best interests of global public health, and that its recommendations are not compromised by politics. And it should re-energize and recommit to its role in leading the Global Health Security Agenda and ensuring that countries continue to subject themselves to rigorous external evaluation. The US should not try to unilaterally ‘own’ a global response to the pandemic – nor could it – but it should provide leadership and resources to a common agenda that will protect its own citizens and economy.

Finally, the administration should look to some of the lessons learned from 9/11. It was clear from the attacks that US government agencies had failed to take seriously a series of factors that clearly signalled the likelihood of a major attack against the US mainland. President George W. Bush and Congress commissioned an in-depth report and analysis, led by a bipartisan and well-respected group of experts and political leaders, which set out a roadmap for reform that remains relevant today. The next administration should commit to a similar process, including by re-evaluating the existing bureaucracies, funding, border screening and global partnerships. It must then commit to implementing these recommendations.

There is no question that when it comes to health security and pandemic preparedness, COVID-19 is not the end of the story. The US must be prepared for whatever next comes its way. The only effective strategy is to reverse the isolationist and antagonistic approach of the last four years, and instead lead a collaborative, multilateral effort to build preparedness and resilience for future catastrophic events.

World Health Organization (2020), ‘WHO Coronavirus Disease (COVID-19) Dashboard’, https://covid19.who.int/region/amro/country/us (accessed 14 Oct. 2020).

Hoffower, H. (2020), ‘Bill Gates has been warning of a global health threat for years. Here are 12 people who seemingly predicted the coronavirus pandemic’. Business Insider, 13 May 2020, https://www.businessinsider.com/people-who-seemingly-predicted-the-coronavirus-pandemic-2020-3?r=US&IR=T#infectious-disease-expert-
michael-osterholm-has-also-been-warning-of-a-global-pandemic-for-the-past-decade-3 (accessed 3 Aug. 2020).

Lee, J.-W. and McKibbin, W. J. (2004), ‘Estimating the Global Economic Costs of SARS’, in Institute of Medicine (2004), Learning from SARS: Preparing for the Next Disease Outbreak: Workshop Summary, Washington, DC: The National Academies Press, pp. 92–109.

See for example European Centre for Disease Prevention and Control (2011), ‘WHO’s Final Report on the functioning of the International Health Regulations (IHR) in relation to the 2009 A(H1N1) pandemic – the Fineberg report’, ECDC comment, 13 June 2011, https://www.ecdc.europa.eu/en/news-events/whos-final-
report-functioning-international-health-regulations-ihr-relation-2009-ah1n1; London School of Hygiene and Tropical Medicine (2015), ‘Independent panel of global experts calls for critical reforms to prevent future pandemics’, https://www.lshtm.ac.uk/newsevents/news/2015/ebola_report.html (accessed 24 Sept. 2020).

United States National Security Council, The White House (1999), A National Security Strategy for a New Century, p. 3, https://clintonwhitehouse5.archives.gov/media/media/pdf/nssr-1299.pdf (accessed 3 Aug. 2020).

Ibid.

The White House, President George W. Bush (2008), ‘Office of National AIDS Policy’, https://georgewbush-
whitehouse.archives.gov/infocus/hivaids (accessed 3 Aug. 2020).

Pilling, D. (2019), ‘Why George W Bush is Africa’s favourite US president’, Financial Times, 17 July 2019, https://www.ft.com/content/72424694-a86e-11e9-984c-fac8325aaa04 (accessed 3 Aug. 2020); Dietrich, J. W. (2007), ‘The Politics of PEPFAR: The President’s Emergency Plan for AIDS Relief’, Ethics & International Affairs, Volume 21.3 (Fall 2007), https://www.carnegiecouncil.org/publications/journal/21_3/essay/001 (accessed 3 Aug. 2020).

Homeland Security Council (2005), National Strategy for Pandemic Influenza, https://www.cdc.gov/flu/pandemic-resources/pdf/pandemic-influenza-strategy-2005.pdf (accessed 23 Sept. 2020).

U.S. Department of Health and Human Services (2020), ‘Public Health Emergency: Biomedical Advanced Research and Development Authority’, https://www.phe.gov/about/barda/Pages/default.aspx (accessed 23 Sept. 2020).

U.S. Centers for Disease Control and Prevention (2010), ‘The 2009 H1N1 Pandemic: Summary Highlights, April 2009–April 2010’, updated 16 June 2010, https://www.cdc.gov/h1n1flu/cdcresponse.htm (accessed 3 Aug. 2020).

Office of the Press Secretary, The White House (2015), ‘FACTSHEET: The Global Health Security Agenda’, https://obamawhitehouse.archives.gov/the-press-office/2015/07/28/fact-sheet-global-health-security-agenda; Global Health Security Agenda (undated), ‘About the GHSA’, https://ghsagenda.org/home/about-the-ghsa (accessed 3 Aug. 2020).

Kirchhoff, C. M. (2016), Memorandum for Ambassador Susan E. Rice: NSC Lessons Learned Study on Ebola, 11 July 2016, https://www.documentcloud.org/documents/6817684-NSC-Ebola-Lessons-Learend-Report-
FINAL-8-28-16.html (accessed 3 Aug. 2020).

Executive Office of the President of the United States (2017), Playbook for Early Response to High-Consequence Emerging Infectious Disease Threats and Biological Incidents, https://www.documentcloud.org/documents/681
9258-Playbook.html#document/p2 (accessed 3 Aug. 2020).

Yong, E. (2020), ‘How the Pandemic Defeated America’, The Atlantic, September 2020, https://www.theatlantic.com/magazine/archive/2020/09/coronavirus-american-failure/614191 (accessed 3 Aug. 2020).

Ibid.

World Health Organization (2020), ‘The Access to COVID-19 Tools (ACT) Accelerator’, https://www.who.int/initiatives/act-accelerator (accessed 16 Aug 2020).

U.S. Department of State (2020), ‘Update on U.S. Withdrawal from the World Health Organization’, 3 September 2020, https://www.state.gov/update-on-u-s-withdrawal-from-the-world-health-organization (accessed 27 Sept 2020).

World Health Organization (2020), ‘Assessed contributions overview for all Member States as at 30 June 2020’, https://www.who.int/about/finances-accountability/funding/AC_Status_Report_2020.pdf?ua=1 (accessed 3 Aug. 2020).

Gaulkin, T (2020), ‘Pandemic failure or convenient scapegoat? How did WHO get here?’, Bulletin of the 
Atomic Scientists, 9 July 2020, https://thebulletin.org/2020/07/pandemic-failure-or-convenient-scapegoat-
how-did-who-get-here (accessed 16 Aug. 2020).