ENDING PANDEMICS: U.S. FOREIGN POLICY TO MITIGATE TODAY'S MAJOR KILLERS, TOMORROW'S OUTBREAKS, AND THE HEALTH IMPACTS OF CLIMATE CHANGE.

• Author: Kavanagh, Matthew M.

Each U.S. President since Jimmy Carter has had to respond to an international outbreak of infectious disease--often multiple (figure 1). While pandemics are biological phenomena, they are highly amenable to political action--through attention, policymaking, and resource allocation. President Reagan's inaction contributed to the growth of the global AIDS pandemic, while President George W. Bush's engagement helped stem its upward trajectory. (1) President Obama's intervention on Ebola, albeit belated, helped galvanize coordinated international action to bring the epidemic under control. (2)

Today, from AIDS to Ebola to mosquito-borne diseases, political action is insufficient. The struggle to respond to the current Ebola outbreak in the Democratic Republic of Congo, the second most lethal in history, illustrates the challenge. (3) Meanwhile, climate change and mass migration are compounding the complexity of the task. How, then, should U.S. foreign policy respond in a world of competing priorities?

This article describes the potential for expanded U.S. foreign policy leadership on pandemics. Saving lives is a worthy goal in itself. The wellbeing of Americans is also inextricably connected with that of people around the world. The oft-repeated reality that diseases know no borders reveals why an approach rooted in international solidarity and multilateralism is needed. We propose a focus on three synergistic areas related to pandemics:

1) halting today's biggest pandemics,

2) keeping tomorrow's outbreaks from becoming pandemics, and

3) reducing the rising threat of infectious diseases associated with climate change.

We focus here on pandemics--epidemics of infectious disease affecting a wide geographic area and large numbers of people, and crossing international borders. (4) This focus is not intended to direct attention away from other global health priorities, but to identify particular opportunities where U.S. political action could be most impactful, and catalytic for international cooperation, given the U.S. geopolitical position and historical investments in infectious disease programs.

In addition, infectious diseases drive global inequality. Despite increasing mortality from non-communicable diseases, people living in poverty continue to die in large numbers from infectious diseases. (5) The effects of pandemics are disproportionately experienced by the poor and marginalized--globally and within countries. (6) Young women in sub-Saharan Africa, gay and bisexual men, and transgender people, for example, still face high burdens from HIV. (7) During the West Africa Ebola epidemic, the disease and economic impact fell hardest on poor communities. (8) Climate change promises to exacerbate adverse effects on marginalized communities.

U.S. administrations in the coming years will have little choice but to address these areas. Progress against AIDS, tuberculosis (TB), and malaria is stalling. Experts agree it is not a question of if, but when, the next major pandemic will occur. (9) The frequency and diversity of new outbreaks is growing, with 7,000 signals of potential outbreaks each month, according to the World Health Organization (WHO). (10) Without additional action, climate change is poised to put nearly a billion people newly at risk of mosquito-borne viruses. (11) Drug-resistant infections are on the rise. (12) Yet there remain major gaps in response and preparedness.

The focus here is on U.S. foreign policy--an area where presidents have the strongest prerogative, even as power is shared with Congress. (13) We describe significant returns to an expanded foreign policy effort, at a presidential level, on pandemics--both in lives saved and improved global economic prosperity. We note, however, that efforts by the U.S. government can only be effective as part of globally-coordinated, multilateral efforts--which are threatened in the current era of isolationism and populism. (14)

The article begins with a brief review of the current context of today's largest pandemics, emerging and re-emerging diseases, and climate-sensitive outbreaks--with brief discussions on opportunities for U.S. action on each. The global economic impact in lost productivity due to infectious disease is then calculated for low- and middle-income countries (LMICs), including fast growing economies and key U.S. trading partners. We also describe estimates of economic return to U.S. investments, which are quite high. (15) We then map U.S. global health spending in recent years on these areas, which totals 0.19% of the federal budget, and close with suggestions about key opportunities for structuring a coordinated U.S. pandemics initiative. Together, there is strong evidence that U.S. leadership could help reduce the pandemics that kill millions today, while preventing tomorrow's outbreaks from becoming global health emergencies and reducing the magnitude and pattern of climate change-related risks.

HALTING TODAY'S PANDEMICS: HIV, TB, MALARIA

After a decade of progress, the response to the world's leading infectious killers--AIDS, TB, and malaria--is faltering. The diseases killed nearly 3 million people last year. (16) Stalled progress is driving inequality as these diseases disproportionately affect marginalized populations including people living in poverty, young women, gay men, children, people who use drugs, and others. (17)

The U.S. has made political and financial investments in multilateral institutions like the Global Fund to Fight AIDS, TB, and Malaria and in bilateral programs including the President's Emergency Plan for AIDS Relief (PEPFAR), the President's Malaria Initiative (PMI), and USAID TB programs (figure 7).

These have augmented domestic financing to achieve results once considered impossible. 23 million people are on HIV treatment; mortality and new infections have been cut in half. (18) An estimated 54 million lives have been saved from TB since 2000 and malaria cases reduced by 20 million. (19) HIV programs have provided critical human rights resources and the only LGBT-friendly healthcare in many settings. Some countries have achieved remarkable results, like Botswana where 77% of all HIV-positive adults know their status and have attained viral suppression, which has been shown to stop HIV transmission. (20) Signs of success on TB and Malaria have also given rise to viable strategies, agreed to by countries at the UN, to end these pandemics as public health threats in the coming two decades. (21)

Yet progress is slipping as growing pandemics have been met with flat or reduced funding. (22) HIV remains the leading global cause of death among people 15-49. (14) Figure 2 shows trends are far off track from goals set at the UN General Assembly in 2016. (23) Too many countries are experiencing rising infections (e.g., Brazil), AIDS deaths (e.g., Angola), or both (e.g., the Philippines). Malaria is on the rise globally and declines in TB have been far smaller than hoped. (24) Drug-resistant TB and malaria are an international threat. (25) Even as some countries approach malaria elimination, 20 of the highest-burden countries saw significant increases in cases.

U.S. foreign policy could contribute toward getting these efforts back on track--with financing and smart diplomacy. First, funding is key. Recent presidential budget proposals have sought cuts to U.S. funding (figure 7). Growing pandemics require increased resources. Key innovations, from new TB treatments, to combination HIV prevention, to community case management for malaria could be scaled immediately, but lack resources. Second, increased multilateralism is needed. The UN, Global Fund, and other institutions provide necessary leverage for inter-governmental and civil society collaboration, making bilateral programs like PEPFAR far more effective, but need a greater share of U.S. political and financial support. Third, active U.S. diplomacy with other wealthy nations is needed since LMICs are increasing their investment but are met with donor reductions. (26) Fourth, diplomatic policy engagement can support rights and evidence-based policies that make money effective. Criminalization of same-sex relationships, for example, is a major barrier to addressing HIV. The State Department has an office of "health diplomacy" that could be given an explicit mission to support law-reform and human rights efforts including effective strategic litigation. (27)

KEEPING TOMORROW'S OUTBREAKS FROM BECOMING PANDEMICS: GLOBAL HEALTH SECURITY

Since the West Africa Ebola epidemic, the WHO, the National Academy of Medicine and others have pointed to the major gaps in ensuring all countries can prevent, detect, and respond to outbreaks. (28) Today, a pathogen like influenza has the potential to travel around the world within hours and could kill tens of millions of people, disrupt economies, and destabilize national security. (29) Modelers predict the emergence of an airborne virus of this sort sometime in the next 10 to 15 years. (30) The number and diversity of disease outbreaks has increased significantly since 1980, even controlling for differences in reporting. (31) Figure 3 shows an analysis of WHO reports on the number of countries experiencing outbreaks in a given year. (32) Climate change, globalization, urbanization, migration, conflict, and antimicrobial resistance contribute to the intensification.

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