A Marshall Plan for Global Health

A worker is seen in the mosquito formulation and vialing room at Sanaria Inc. facility in Rockville, Maryland, October 26, 2007. The insects in the facility are dissected for the motherlode that they carry -- baby malaria parasites, with which founder and chief executive officer Dr. Stephen Hoffman hopes he can do what has been impossible -- make a vaccine against malaria. REUTERS/Jim Young (UNITED STATES)

It’s in America’s own interest to regard global epidemics as not only a humanitarian problem, but a consequential matter of national security.

January-February 2018

Supporting global health helps to suppress epidemics and foster more resilient workforces—creating more opportunities for American businesses to invest and form meaningful international partnerships. Take, for instance, sub-Saharan Africa. From the perspective of an American interest, including that of the U.S.-headquartered business community, this is the region that has the greatest economic potential and highest rates of growth in the world. Fighting disease there has been an investment in serving that growth and interest. Supporting the health of struggling populations on a global scale has the potential to open valuable doors for economic opportunity and prosperity.

WHEN PROPOSING the PEPFAR program in his 2003 State of the Union address, then president George W. Bush stated, “Seldom has history offered a greater opportunity to do so much for so many.” By providing 11.5 million people with art, preventing HIV transmission to two million babies, and supporting HIV testing and counseling for 74.3 million people, PEPFAR has indeed achieved good for many. Global health aid serves to reinforce America’s role as a generous and humane guarantor of world order and has demonstrably built our soft power—global influence to persuade as well as militarily coerce.

Global health investments can benefit us as a nation by improving the United States’ standing among the leaders and populations of nations of strategic consequence. In the launch, conduct and outcomes of wars in Afghanistan and Iraq, President Bush’s presidency faced many points of heated criticism. Near the end of his presidency, a 2008 Pew Global Attitudes Project survey in twenty-four major countries around the world found that of the twenty-one outside sub-Saharan Africa, only in four (Britain, Poland, South Korea and India) did more than 50 percent of the population have a favorable view of the United States. In contrast, PEPFAR recipient countries reflected a different view. During the Bush administration, PEPFAR nations had a 68 percent approval rating of the United States, compared to the 46 percent global approval rating. This was particularly the case in sub-Saharan Africa. Among the positive developments that have coincided with this goodwill is the creation of the U.S. military’s African Command (AFRICOM) and success in eliciting African nations’ burden sharing in supplying their troops for multilateral peacekeeping missions.

In this regard, vital U.S. interests on the African continent—vis-à-vis China as a rapidly growing regional influence—point to further implications of global health policy. African nations hold vast economic potential. This is especially true in the sectors of agriculture, natural resources, energy production and infrastructure development. African maritime zones alone make up a total of thirteen million square kilometers, many of which are largely undeveloped with regard to infrastructure and resource exploration. Most of all, potential economic development on the continent would be deeply beneficial to the people of Africa. Yet it represents opportunities for the rest of the world too: less tapped and saturated economies for labor, along with resources and sales, hold the greatest lure—to the United States as well as to China.

The Chinese government has sensed Africa’s growing importance—especially as China’s own booming economy has an immense demand for the absorption of natural resources, from energy to minerals. The country has taken aggressive steps to ensure its stake in the continent’s potential. In 2003, Chinese investments and aid to Africa only totaled $70 million. Most recently, Beijing has promised a $60 billion loan and aid package to all the African countries combined. Along with this increase in assistance is a rise in economic interaction: Africa’s exports to China increased sixtyfold from 1998 to 2010 compared to the fivefold increase to the United States. If Washington keeps advancing health—specifically, a path to epidemiological control of HIV, TB and malaria in sub-Saharan Africa—it maintains an important form of influence on the continent. In the Trump era—even if it were to pursue the sort of business and infrastructure investments that China is making—the United States would lose an advantage in the battle for economic, diplomatic and strategic influence in Africa by decelerating its well-known investment in health.

Additionally, global health aid serves American interests as an underappreciated tool among the many efforts contributing to the diffusion of conflict and instability in partner nations. For instance, in PEPFAR countries, violence and political instability between 2004 and 2013 were reduced by 40 percent in contrast to 3 percent in non-PEPFAR countries. Furthermore, rule-of-law ratings also rose by 31 percent in PEPFAR countries during this time period versus only 7 percent in non-PEPFAR countries. U.S. programs focused on addressing particularly disruptive health phenomena facilitate peace, pluralism and prosperity consequential to our national interests.

The Trump administration and House Republicans have proposed a hard-power focus. However, it is important to diversify our toolbox in advancing U.S. influence abroad, rather than solely doubling down on the military instrument at the expense of other valuable means. Robert Gates, secretary of defense under both George W. Bush and Barack Obama, has observed: