U.S. Global Health Leadership Must Go Beyond Command and Control

The administration of President Joe Biden and Vice President Kamala Harris is on the verge of reasserting U.S. leadership in global health and development. In his first hundred days, Biden made the United States the largest single donor to the global vaccination campaign known as COVAX, co-sponsored by the World Health Organization; appointed a coordinator for global COVID response and health security; and included funding for global health in the signature American Rescue Plan to respond to COVID-19. These actions, on top of Biden’s decision to renew U.S. membership in the WHO immediately upon taking office, reverse the go-it-alone isolationism that characterized the previous administration’s response to COVID-19 and to global health in general.

As welcome as these gestures are, the world may greet the return of American global health leadership with some justifiable ambivalence after four damaging years under President Donald Trump. Humility, some analysts have suggested, may be in order for the country that would lead again. Writing in The New York Times last December, columnist Peter Beinart concluded that “in the post-Trump age, ‘leadership’ is a misguided, and even dangerous, vision for America’s relationship with the rest of the globe.” Beinart emphasized the importance of “partnership” and “solidarity” instead, arguing that as the United States rejoins common global efforts from climate action to COVID-19, it “best serves these efforts less by dictating the rules than by agreeing to them.”

The point is particularly well taken in the realm of global health. In the last year, public health officials have found themselves “dictating the rules” a lot, on everything from handwashing to social distancing to masking. But health experts have equally emphasized the importance of leading with compassion in responding to the pandemic; of engaging in the participatory decision-making traditionally associated with female leaders; and of embodying the qualities of truthfulness, humility, and equity as the foundation of effective public health leadership.

One lesson that the United States can fruitfully draw from the experience of this pandemic is that the world needs more American leadership in global health, not less—but that the United States has a distinct opportunity to model a style of leadership that goes beyond the command and control of others.

Power Is Abundant

Renewing American leadership in global health may require confronting what economists sometimes refer to as the myth or fallacy of scarcity: the notion that there are simply not enough goods to go around. Often the goods in demand are vaccines, food, economic opportunities, or agricultural land. The notion of food scarcity, for example, spurs efforts to produce more food and ship it more efficiently; but far from solving the problem, these measures can sometimes increase prices and make food less affordable. As the economist Amartya Sen has argued, the alternative is to recognize that there is in fact abundant food to go around, but entrenched barriers limit its accessibility and affordability. Lifting those barriers means tackling such systemic problems as poverty, inequality, corruption, and conflict.

The idea that resources become abundant if approached systemically does not apply only to tangible commodities but also to power itself. Philosophers and political scientists have long debated whether power should be understood as zero sum—meaning that there is only a certain amount of power to go around, and the more power I have, the less power you have—or variable sum, meaning that cooperation can produce mutual gains, so long as they are offset by mutual losses elsewhere. Such cooperation can occur even in a context of vastly unequal power relations, particularly if one abandons the ideas that one party is powerful because another party is less powerful, that all human desires need to be achieved at another’s expense, and that conflict and cooperation are always mutually exclusive. 

How can American leadership in global health move beyond scarcity and zero-sum thinking? A good place to start would be with COVID-19 vaccine access. In a recent response to accusations that the United States was hoarding vaccine supplies from poorer nations, Biden insisted that Americans would come first: “If we have a surplus, we’re going to share it with the rest of the world.” This is classic scarcity thinking, grounded in the stark reality that when the U.S. president made the statement, there were manifestly not enough doses to go around.

Yet in the same speech, Biden went on to undercut the scarcity model by announcing that the United States would partner with Australia, India, and Japan to expand global vaccine manufacturing capacity. More recently, the U.S. trade representative announced her support for a waiver of intellectual property rules to facilitate the manufacture of COVID-19 vaccines globally. These kinds of solutions are sustainable because they recognize that the more the know-how to manufacture vaccines expands, the less scarcity will be a problem. They are also smart development policy because they make other countries less reliant on American handouts to meet their vaccine needs, strengthening their capacities to respond to this and future pandemics. Biden should consider taking the same logic a step further by, for example, urging American pharmaceutical companies to share licenses through the COVID-19 Technology Access Pool (CTAP), a globally coordinated mechanism proposed by Costa Rica and started by the WHO last year.

Reject False Choices

In the past year, the American discourse about public health has been plagued by false choices—in particular, between individual and economic freedom on the one hand and collective security and public health on the other.

COVID-19 is not the first public health emergency to raise questions about individual freedom. Such concerns have accompanied the forced detention of people with tuberculosis, involuntary or “opt out” testing for HIV, and the creation of cordons sanitaires to prevent people from leaving areas infected with virulent diseases, such as Ebola. But during these pandemics, effective solutions have emerged—such as directly observed therapy for tuberculosis as an alternative to detention and comprehensive reproductive and HIV care as an alternative to the forced testing of pregnant women—that demonstrated that the tradeoff was not inevitable. Providing people with comprehensive services and supports can achieve public health goals without infringing personal liberties.

Effective public health measures that do not restrict liberties may be more expensive and difficult to implement in the short term than those that do. To achieve them will require that policymakers abstain from exaggerating the false choice between economic freedom and public health.  Trump’s call to “Free Michigan!” from COVID-19 lockdowns and his attacks on Anthony Fauci, the director of the U.S. National Institute of Allergy and Infectious Disease, calling him an “idiot” and a “disaster,” reflected this false choice—as did the actions of Trump’s opponents when they focused on denouncing his attacks on science and public health rather than on furnishing the economic and social support that Americans would need to carry them through the pandemic.

The world needs more American leadership in global health, not less.

In his first hundred days, Biden has largely resisted the seduction of binary thinking about the pandemic. His ambitious COVID-19 relief packages manifest the kind of “help is on the way” leadership that breaks down false choices and depoliticizes the pandemic. Biden told the staff of the Centers of Disease Control, “The public is thankful to you, because it’s about science”—but he also made clear with his economic policies that he knew that social distancing was only as effective as the ability of individuals to follow scientific advice.

The Biden administration should take a similar approach to leadership on global health. The United States should provide technical assistance on the scientific dimension of the crisis, but it should also help less wealthy countries navigate the apparent tradeoff between economic development and pandemic control. This tradeoff will be even more pronounced—and subject to political manipulation—in countries with high levels of poverty and weak governance, where politicians can easily invoke economic development as a reason to flout health safeguards or weaponize public health countermeasures to shut down civil society and political opposition. Rather than getting drawn into these false dilemmas, the United States should counteract them by helping its allies provide their people the economic and social supports they need to survive a pandemic and earn a livelihood. To this end, the United States should promote policies, such as progressive taxation and debt relief, that create the fiscal space for U.S. development partners to provide a social safety net.

Address Inequity

One of the most pervasive refrains of the past year has been that COVID-19 “does not discriminate.” “I know it sounds trite to say, but we’re all in this together,” Biden declared following his election in November 2020. But many have also pointed to deep inequities in the pandemic’s spread, impact, and response. The virus circulates with particularly deadly efficiency among people who perform essential work in crowded spaces; those who live in dense neighborhoods, multigenerational homes, and congregate settings; and those who suffer from preexisting vulnerabilities such as chronic disease, stress, and food insecurity. In the United States, all these conditions intersect with race and immigrant status, a reality that Biden acknowledged in creating a COVID-19 Health Equity Task Force that draws diverse expertise from affected communities.

During the Trump years, the United States sidelined its knowledge of and commitment to health equity. But the expertise and ingenuity were there all along and now have the opportunity to take center stage, not only in U.S. policy but on a global scale. Washington could, for example, deploy experts to counsel other governments on using data to analyze whether vaccines, treatments, and testing are reaching those who need them most and how this distribution is affecting the course of the epidemic for the whole population. And in countries where race creates disparities in conditions that ultimately determine health, such as housing and employment, the United States should share the experience and solutions that are only now getting the attention they deserve domestically. Such a commitment would be consistent with the “can-do” approach to American foreign policy that Samantha Power, now the head of USAID, has recommended—an approach that shares expertise rather than modeling incompetence and isolationism as the last administration did.

On a more transformational level, leading globally on health equity means taking a hard look at the field of global health itself. A growing number of development experts and practitioners are calling on their colleagues to rethink assumptions and practices rooted in an imperial past. Local scholarship on health and development in many developing countries has been underresourced, as power and prestige has instead flowed to foreign researchers studying the health of low- and middle-income countries. Development priorities are often set in remote global capitals, and charity and voluntarism too often substitute for reforms to the health systems whose weakness fuels aid dependency in the first place. A growing movement questioning these arrangements calls on donors, such as the United States, to put money and power into the hands of communities, local practitioners, and progressive government officials responding to health threats rather than viewing them as passive beneficiaries of Western largess. The United States can lead in this area in a manner consistent with the Biden administration’s express commitment to racial equality by first meeting targets for the proportion of American aid that goes directly to local and national groups.

Leadership of Imagination

The United States neither can nor should abdicate a strong leadership role in global health. The question is how it leads. The traditional style has tended to accept constraints that are ultimately self-imposed. These include the myth of scarcity, the lure of false choices, and the perpetuation of exclusion. The United States should instead embrace a leadership style that emphasizes sharing abundant power, strengthening public safety nets, and including a greater diversity of voices in decision-making and implementation.

The traditional constraints have impeded progress in global health. But they are not inevitable. Leadership is precisely about the courage to see beyond received wisdom and to tell a new story. “We can only vaccinate the world after we vaccinate ourselves.” “We need to sacrifice our freedom to prevent contagion.” “Diseases don’t discriminate.” These refrains represent a failure of imagination—a failure to recognize that human health is not only about the presence or absence of disease but also the conditions that make full mental and physical wellness attainable for all. Achieving such a vision of health requires imagination freed of self-imposed constraints. Such imagination may be the hallmark of global health leadership in 2021.