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June 2017 (Volume 95)
Quarterly Article
Lawrence O. Gostin
December 2024
Dec 19, 2024
Back to The Milbank Quarterly
In his inaugural speech, President Trump said, “From this day forward, it’s going to be only America first.” The term has an ugly history, which can be traced to the America First Committee that opposed any US involvement in World War II, with undertones of anti-Semitism.1
As an expression of nationalistic populism, “America First” is in tension with the global common good. While governments have duties toward their citizens, a nation’s health can be effectively secured only through international cooperation. Trump’s political philosophy—erecting walls (literally and figuratively) and distrusting international law and institutions—rejects core values of shared responsibility and mutual solidarity. In particular, the following 5 policies would make America, and the world, less healthy and secure.
Mexico City: Reproductive Health
Since enactment of the 1973 Helms Amendment, US foreign aid cannot be used to conduct abortions. The Mexico City policy, first adopted in 1984 by President Reagan, goes further: recipients of USAID funds cannot conduct, refer, counsel, or even advocate for abortion, even if they use non-US funds. (All Republican presidents have adopted this policy, while all Democratic presidents have rejected it.) President Trump significantly extended the reach of the so-called gag rule, which now covers all US global health funding ($10.3 billion),2 including the President’s Emergency Plan for AIDS Relief (PEPFAR), Centers for Disease Control and Prevention (CDC), and National Institutes for Health funding. The policy jeopardizes vital programs on HIV/AIDS, Zika, and maternal/child health. Reproductive health clinics are forced to choose: declare allegiance to US policy or accept drastic funding cuts. When clinics must turn away poor women due to scarcity of funding, the result is predictable. Research demonstrates the policy increases abortions and endangers the health and lives of women and children.3 The US Supreme Court struck down a domestic gag rule requiring AIDS groups to have a policy explicitly opposing prostitution and sex trafficking on free speech grounds (Agency for International Development v. Alliance for Open Society International, 570 US [2013]), but this doesn’t apply overseas.
Refugee Ban
Within a week of his inauguration, President Trump issued an executive order barring Syrian refugees indefinitely, all other refugees for 120 days, and travel from 7 Muslim-majority countries for 90 days. The temporary ban separated families, stranded travelers, and prevented students, skilled workers, and sick patients from coming to America. Yet, nationals from these 7 countries have not carried out a single terrorist act on US soil. Instead of responding to a clear threat, this policy targets some of the most vulnerable children; UNICEF recently ranked 5 of the 7 countries among the world’s most hazardous. The order looks like a subterfuge for discrimination—Trump once demanded a “complete shutdown of Muslims from entering the US,” and his executive order targets predominantly Muslim countries. The travel and refugee bans betray American values of tolerance, inclusiveness, and diversity. The Ninth Circuit stayed the ban as presumptively unconstitutional.4 The president subsequently issued a new executive order addressing certain constitutional deficiencies, such as exempting green card holders and giving detailed notice of restrictions for individuals with current or pending visas. He also withdrew Iraq from the list of banned countries. However, a federal judge in Hawaii blocked the order, hours before it was to come into force, based on a high likelihood that the plaintiff’s, and the people of Hawaii’s, constitutional rights would be violated.
Global Health Security Agenda
In 2014 President Obama launched the Global Health Security Agenda (GHSA)—a multisectoral and multilateral program endowed with $1 billion in funding to support global health security. President Obama was motivated by beneficence, but also a realization that America’s safety depends on all countries building strong health systems to prevent, rapidly detect, report, and contain infectious diseases at their source. GHSA fills major gaps by offering states economic and technical support to implement and go beyond international norms, such as the World Health Organization (WHO) International Health Regulations. The program requires partner countries to use rigorous matrices and conduct independent evaluations of their capabilities. GHSA has become a model of US global health leadership, enabling the CDC to work with WHO and more than 50 partner countries toward a safer world. In the wake of Ebola, WHO also formed the Joint External Evaluation Tool, employing GHSA technical excellence and funding. Failure to support GHSA reauthorization would undermine American leadership, making the world more vulnerable to deadly infectious diseases. Trump has already shown himself reactionary in the face of infectious diseases, urging President Obama to prevent US aid workers in West Africa from returning home to receive lifesaving treatment and supporting quarantines without due process of law.
PEPFAR: HIV/AIDS
President George W. Bush launched PEPFAR in 2005, as the largest global health commitment in history. Congress authorized a total of $72 billion through FY2016. PEPFAR is driven by values of shared responsibility among donor and partner nations to save lives through prevention and treatment. Before PEPFAR, HIV/AIDS was demolishing the African continent, robbing nations of teachers, doctors, and parents in their prime, while crushing Africa’s economic revival. Today, 11.5 million Africans are receiving lifesaving antiretroviral treatment, 2 million babies have been born AIDS-free, 1 million adolescent girls have been supported in achieving an AIDS-free future, and 6.2 million orphans and children receive care and support. Congress allocated nearly $7 billion to PEPFAR in FY2016, but will President Trump support this level or increased funding this year and beyond? Failure to do so would break a robust bipartisan consensus. In 2008, President Bush said PEPFAR’s greatest achievement is “hope,” and “spreading hope is in our moral interests because . . . to whom much is given, much is required.”
WHO and the UN System
WHO and the United Nations (UN) system form the foundation for a healthier, safer world. WHO is the world’s premier health agency tasked with stemming threats that span borders, from injuries and noncommunicable diseases to infectious diseases, such as currently circulating avian influenzas in China, Middle Eastern Respiratory Disease in Saudi Arabia, and Zika throughout the Americas. The UN system—from central organs such as the Security Council and General Assembly to specialized agencies such as UNICEF—stands as a political bulwark pushing countries to fight salient health threats, such as antimicrobial resistance, access to medicines, and human resources. Above all, the UN Sustainable Development Goals set major health targets, such as universal health coverage. Yet, WHO is financially and structurally weak, with a budget roughly one-quarter that of the CDC and less than many large US hospitals. The UN system is also fractured and often paralyzed by political inertia, unable to stop the spread of cholera in Haiti and break the political deadlock in Syria that has led to the biggest outpouring of refugees since World War II. Rather than backing internal reforms and sustainable funding, President Trump appears hostile to international law and institutions. He has expressed heavy skepticism about international organizations and norms—promising to tear up the Paris Agreement on climate change; vowing review of multilateral treaties on trade; threatening to cut US financial contributions to UN agencies; and declaring the UN “weak,” “incompetent,” and “unfriendly” to America.5
“America First”
This is what President Trump means by “America First”: imposing Republican abortion orthodoxy on poor countries, banning entry of the world’s most vulnerable people, singling out a religion for global censure, undermining international institutions and norms, and quite possibly welching on long-standing US financial commitments on AIDS and global health security. By putting the global common good last, the president is rapidly eroding US standing in the world and making Americans less healthy and secure.
References
Lawrence O. Gostin is University Professor in Global Health Law at Georgetown University, faculty director of the O’Neill Institute for National and Global Health Law, and director of the World Health Organization (WHO) Collaborating Center on Public Health Law and Human Rights. He has chaired numerous National Academy of Sciences committees, proposed a Framework Convention on Global Health endorsed by the United Nations Secretary General, served on the WHO Director’s Ad Hoc Advisory Committee on Reforming the WHO, drafted a Model Public Health Law for the WHO and the Centers for Disease Control and Prevention, and directed the National Council of Civil Liberties and the National Association for Mental Health in the United Kingdom, where he wrote the Mental Health Act and brought landmark cases before the European Court of Human Rights. In the United Kingdom, he was awarded the Rosemary Delbridge Prize for the person “who has most influenced Parliament and government to act for the welfare of society.”
