The Trump budget: what does it mean for global health?

WHO NEEDS PREVENTION ANYWAY?

The Department of Health and Human Services, National Institutes of Health (NIH), and Centers for Disease Control and Prevention (CDC) face cuts of around 18%. Billions of dollars worth of prevention programmes are being replaced with a single $500m block grant. Cutting prevention is frankly myopic and comes with the risk that states in the US will use grant monies to plug holes in general budgets, rather than spending on public health (this sounds similar to what is going on in the UK). Tom Friedman, director of the CDC, condemned the proposals as ‘unsafe at any level of enactment’, arguing that they will ‘increase illness, death, risks to Americans, and health care costs’.³

These cuts primarily harm Americans, but their impact will ripple around the globe. The NIH is currently the world’s largest public funder of biomedical research and the CDC is a leading producer of global public goods like training, surveillance, evidence synthesis, standard generation, and leadership. The domestic downsize will weaken health systems around the world.

DANGEROUS SHORT-TERMISM

Reciprocally, defunding global health will ripple back to undermine American health and security. GAVI, the vaccines alliance, is to receive a modest $15m increase but every other global health programme is being eviscerated or eliminated. High-profile cuts include those to programmes fighting TB and malaria (−$194m), neglected tropical diseases (−$25m), maternal and child health (−$80m), and contributions to the Global Fund to Fight AIDS, TB and Malaria (−$225m). Support for international organisations will fall by 44% and budgets for family planning, vulnerable children, and HIV have been completely ‘zeroed out’.

America is by far the biggest supporter of global health programmes and a withdrawal on this scale will be catastrophic, leading to millions of excess deaths in the world’s poorest countries. Food aid is being taken away from 38 million people at a time when Yemen, Somalia, Nigeria, and South Sudan all face major famines. Advances against polio, TB, HIV, and malaria will be undermined and the world will be slower to respond to emerging pandemics. The family planning cuts alone will lead to an additional 15 000 maternal deaths, 3.3 million unsafe abortions, and 8 million unintended pregnancies per year.⁴ Assistance for refugees, international disaster response, and UN peacekeeping are all being shortchanged by billions of dollars, along with USAID and the State Department. ‘Gutting American soft power’, as one Republican senator put it, will ferment political unrest and potentiate misery for millions. Far from putting America first, scaling back global health programmes will come back to haunt the US.

A SMALL SLICE OF A BIG PIE

The cuts are being framed as reversing profligacy and forcing other countries to start pulling their own weight. America’s financial contributions are huge in absolute terms,⁵ but the US actually donates a much smaller slice of the pie than other countries: aid spending constitutes 0.18% of US Gross National Income — four times less than the UK (0.7%).⁶

America’s peers understand that investing in global health serves Western interests: by building healthy consumer markets, reducing migration ‘push’ factors, and buttressing soft power in fragile states. Trump’s cuts appeal to the millions who don’t see direct benefits from overseas development, and voters will always struggle to comprehend averted counterfactual deaths.

Budget proposals are primarily a means of outlining priorities and Congress will heavily edit the document before giving its approval. Nevertheless, Trump’s commitment to radically reducing global health spending makes major programme closures inevitable. This near-sighted abdication of moral, intellectual, and technical leadership will levy a leviathan human toll in terms of death and disease, lost economic output, and geopolitical instability. With this budget Trump is certainly laying a foundation, but it is not one of American greatness.