Trump’s Battle Against Breastfeeding Is a Small Part of a Wider War

At the turn of the century, I published a book called Betrayal of Trust: The Collapse of Global Public Health, in which I argued that population health rises or falls based on trust established between citizens and governments. If the people lose faith in government, science, and each other, the entire public health house of cards can quickly collapse. In the following years, the momentum behind globalization inspired the creation of public health initiatives such as the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the Global Fund, and hundreds of smaller nongovernmental health groups.

Today, trust and solidarity between nations, and within them, are yielding to what some have characterized as modern tribalism. And, unsurprisingly, the edifice of global public health is starting to come down with it. This is nowhere more visible than in the United States under the influence of President Donald Trump, whose nationalist agenda has amounted to a multifront war on global public health.

Last week, the New York Times reported that the Trump administration attempted to block passage of a resolution at the May World Health Assembly in support of breast milk. At issue was language meant to strengthen the 1981 International Code of Marketing of Breast-milk Substitutes, aimed at stopping false claims that powdered formula is equal to, or even superior to, mothers’ milk. Experts argue that formula made by the 800 million people in 2018 having no access to safe drinking water contributes to the deaths of 820,000 babies annually. Moreover, there is plentiful evidence that breast milk contains components of the immune system and mother’s microbiome that protect infants from disease and promote healthy growth.

At the World Health Assembly, the Ecuador delegation sought to strengthen the 1981 code, planning to introduce a resolution favoring breast milk as the best for feeding infants. The U.S. delegation threatened to revoke some military aid and cut trade with Ecuador, acting in defense of the $70 billion baby formula industry. And Trump tweeted, “We don’t believe women should be denied access to formula.” Ecuador dropped its resolution, and global health leaders were appalled, viewing the attempt to protect the formula industry as placing U.S. companies’ profits above the health and survival of babies.

The Trump administration is also seeking to put U.S. pharmaceutical industry profits back in the driver’s seat in global pricing schemes. In February, the White House Council of Economic Advisers said that pharmaceutical price controls in the European Union constituted “free-riding” off U.S. taxpayers, who generally pay far more for medicines than do Europeans. In a May speech, Trump claimed other governments “extort unreasonably low prices from U.S. drugmakers,” adding that, “America will not be cheated any longer and especially will not be cheated by foreign countries.” Meanwhile, in the lead-up to the United Nations General Assembly’s discussion this fall about tuberculosis, the United States has tried to block references to fair pricing and World Trade Organization clauses that aim to make innovative medicines affordable in poor countries.

Amid rising trade tensions between the United States and most of the wealthy world, Trump has suggested he may pull the United States out of the WTO entirely, threatening to tear down the institution that since 1995 has prevented unfair trade practices and economic wars through a set of global rules and conflict resolution processes. For global health, the most vital of these rules is a special set of exceptions in WTO intellectual property agreements that allow governments to issue compulsory licenses — going around drug company patents — in the event of a national public health emergency. During the anthrax murders in the United States in 2001, then-Secretary of Health and Human Services Tommy Thompson threatened compulsory licensing against the German company Bayer to drive down the price of its patented drug ciprofloxacin, which is used to treat anthrax. Many African countries have used the mechanism to drive down the costs of medicines for HIV, TB, malaria, and hepatitis infections.

It is impossible to reckon how many lives would be lost worldwide were the WTO to collapse and its emergency provisions that currently make medicines affordable in poor and middle-income countries by encouraging generic manufacture of still-patented products evaporated. Surely, if prices for HIV medicines were allowed to rise from their current low of roughly $75 per year per person in poor countries to the cost of a typical equivalent treatment in the United States of about $3,600 per year, millions of lives would be lost, purely for financial reasons. According to the U.N. AIDS program, about 21 million people are currently surviving with HIV thanks to these daily drugs, and another 16 million need such treatment. Despite that unmet need, global financing for HIV/AIDS has declined 5.4 percent each year since 2012, leaving a current shortfall of $16.2 billion needed to keep the anti-pandemic juggernaut on track until the end of 2020.

The existence of several global health institutions is also at stake. In July 2000, the G-8 met in Okinawa, where the Japanese government pushed through a resolution on infectious diseases, calling for creation of a Global Health Fund. Now called the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Geneva-based organization disperses about $4 billion a year to fight and treat the three diseases. Until the 2008 world financial crisis, members of the G-8 and other donors gave generously, in a steadily rising manner, to the fund. But as the world descended into recession, donations ebbed. Under the Trump administration, which heralds a soaring U.S. economy, commitments to the fund have gone unfilled for political reasons. Though Washington committed about $1.4 billion per year to the fund for 2017, 2018, and 2019, about $875 million of that went unpaid in 2017, none has been paid this year, and the 2019 budget has yet to reach a vote in Congress. Experts openly question whether the Global Fund will survive after 2019, and if so, in what diminished form.

Survival is also at issue for the World Health Organization, which operates on two-year budgets of about $2.6 billion. Less than a fifth of that comes from a sort of dues system, with 194 member states and two associate members assessed an annual payment based on their GDP. But the assessed portion of WHO’s budget is trivial, because about 80 percent of its funds are donated voluntarily and are earmarked by the giver for specific programs. Highly dependent upon three voluntary donors — the U.S. government ($343.7 million in 2017), the Bill & Melinda Gates Foundation ($261.9 million), and the U.K. government ($164.4 million) — that together underwrite more than 40 percent of its voluntary funding, WHO is both extremely vulnerable to political changes in Washington and London, and compelled to model its programs to suit these big three. Though U.K. Prime Minister Theresa May’s government has been at pains to reassure its global health and development recipients that funding is secure, no such assurances have been forthcoming from the Trump administration.

Meanwhile, there is rising anxiety in Washington about the Trump administration’s plans for the PEPFAR AIDS program, the world’s largest disease-specific global health effort, which was created by President George W. Bush in 2003 to treat and prevent AIDS in Africa. A new analysis from the Bipartisan Policy Center concluded that 14 million people are alive today thanks to PEPFAR financing of HIV drugs, and 2.2 million babies have been born uninfected because their mothers were provided medicine during pregnancy and breastfeeding to block transmission to their young. The White House sought to slash PEPFAR in fiscal year 2018 by $850 million and cut its Global Fund contribution by $225 million — in both cases, Congress ignored the Trump administration’s requests. Amid rumors Trump wants to eliminate a third of PEPFAR’s financing, former Vice President Joe Biden and former Senate Majority Leader Bill Frist recently issued a bipartisan plea to protect the program.

Finally, in a remarkable turn of events, opposition to vaccination has been embraced by right-wing and populist organizations all over the world, even in countries with significant outbreaks and deaths due to completely preventable illnesses. Italy, for example, had almost 4,900 cases of measles in 2017, fueled by rising parental opposition to vaccination of their children. That year, the government passed a law mandating all children receive immunization against a variety of diseases as a requirement for school admission. But in March, national elections swept into power a coalition that includes far-right-wing parties that hope to overturn the law. On July 5, the government eliminated the law’s requirement that parents present documentation of vaccination, telling schools to simply trust that families will comply.

No technology has saved more lives over the last 60 years than immunization. But opposition to vaccines is rising around the world. Brazil, for example, is in the grips of outbreaks of measles, yellow fever, and other vaccine-preventable illnesses, but child vaccination rates are now at their lowest in 16 years. Nine North and South American countries reported measles outbreaks this year — the most widespread incidence in the region in two decades. A London School of Hygiene and Tropical Medicine survey of 67 countries found the strongest opposition was in Europe, where fewer parents agree to immunize their kids every year and rates of measles illness and deaths have, as a direct result, soared by 300 percent. According to the European Centre for Disease Prevention and Control, 25 people, mostly children under 5, have died of measles in 2018, with outbreaks focused in Romania (3,284 cases to date), France (2,306), Greece (2,097), and Italy (1,258): 84 percent of Europe’s cases weren’t vaccinated. In one April week, more than 1,000 people in Ukraine contracted measles.

Across the United States, hotspots of vaccine opposition correlate tightly with outbreaks of diphtheria, whooping cough, and measles. To appreciate how ardent vaccine opponents are, watch videos shot in Trenton when New Jersey state legislators held hearings about a possible mandatory child immunization bill. Trump has tweeted skepticism about vaccines, falsely claiming they cause autism, more than 20 times.

The greatest threats to humanity today are of our species’ own making: climate change, loss of biodiversity, plagues, diminished drug effectiveness, war, terrorism, drought, water scarcity, and swelling human populations. No one nation operating in isolation can stop a pandemic, reverse carbon dioxide buildup in the atmosphere, put a halt to the spread of drug-resistant microbes, finally conquer HIV, or create a nonpolluting energy source for all of humanity. The U.N. continues to target 17 sustainable development goals it aims to reach over the next 12 years, among them, “Good health and well-being.” None of them can be reached unless well over $4.5 trillion in funding support flows from wealthy nations to poorer ones. The G-7 represented the driving force behind this mammoth task. Now the G-7, and the agencies it leans on such as the World Bank and International Monetary Fund, are struggling. As Trump made clear in June at the G-7 summit in Quebec, and last week at the NATO gathering in Brussels, the United States will only stay in alliances that are distinctly advantageous to it — a position that, if replicated by other nationalistic governments, would surely weaken and possibly destroy most of the alliances and multilateral institutions that made the global health triumphs of the first 18 years of this century possible.

As trust breaks down further between nations, and within them, every facet of public health will be sorely challenged. The global institutions created to stop epidemics and promote health will, in the near term, try to regain public trust and find alternative sources of funding to stay alive. But their longer-term missions of universal health cannot possibly be realized in the previously trustful world that Donald Trump, Vladimir Putin, and Xi Jinping are now unraveling.