The implications of Donald Trump’s win for the future of global health, by Laurie Garrett

… AND THE OTHER ELECTION: THE WORLD HEALTH ORGANIZATION

Council of Foreign Relations                                                             November 9, 2016

Dear Friends and Colleagues,

The first of two elections with profound consequences for global health has been held—the U.S. presidential and congressional race. The second—the election of a new director general of the World Health Organization (WHO)—will soon be decided.

But first—the implications of Donald Trump’s win for the future of global health.

WHY TRUMP’S WIN MATTERS FOR GLOBAL HEALTH

On every conceivable issue, Americans had two very different options to choose from. Democrat Hillary Clinton and Republican Donald Trump not only disagreed about everything, but also, in many ways, had differing interpretations of the reality from which they drew policy decisions. Facts were in dispute.

And a word of caution is needed, not only for Americans on the day after this election but also for the entire world—we do not know what President Donald Trump will do once he is in the Oval Office. During the campaign, Trump repeatedly told his followers that his momentum was a “movement,” not a classic presidential run. How thatmovement will translate into governance is unclear. We can make guesses, based on Trump’s rhetoric and a limited amount of published policy material, but there will certainly be surprises. The Brexit surprise and its aftermath offer clues to what the first one hundred days of a Donald Trump presidency might bring—uncertainty prevails in both the United Kingdom and Europe regarding every aspect of the process of disentangling Britain from the union, and the anxiety it provoked has prompted market volatility and a broad range of planning difficulties for public and private sectors across Europe.

Perhaps a better example of what is in store is the first one hundred days of the George W. Bush administration in 2001, during which the largest tax reform package in American history was enacted and U.S. foreign policy was upended. Historically, new presidents who sweep into office with their party in control of both houses of Congress carry their campaign momentum into legislation as swiftly as possible, hoping to push their agenda through before the opposition party musters a strategy for blocking passage of appointments and bills. Much of the Trump effect will likely be clear by March 2017, based on the new president’s ambassadorial and governmental appointments. One close observer in Washington tells me there is already talk of an exodus of U.S. government employees, trying to jump out of the government before entire departments or agencies are severely diminished or eliminated.

Most uncertainties regarding Trump policies will likely be resolved during the transition, as the names of his cabinet and White House staff appointments emerge. If, for example, former New York Mayor Rudolph Giuliani and current New Jersey Governor Chris Christie are rewarded for their steadfast support of Trump with positions like attorney general and Supreme Court justice, the direction of American law enforcement, the FBI, and the justice system will be apparent. If, as is rumored, former Congressman Newt Gingrich is named secretary of state or defense, the world will be able to draw from a rich body of Gingrich literature in imagining likely foreign policy initiatives.

What do we know on November 9, 2016?

One major global health program, the President’s Emergency Plan for AIDS Relief (PEPFAR) has enjoyed bipartisan support since its 2002 creation by President George W. Bush, and has expanded. Its fiscal year 2016 budget is $6.8 billion. Both Hillary Clinton and Donald Trump offered support for PEPFAR’s continued existence. Asked if PEPFAR should aim to double by 2020 the number of people worldwide who receive anti-HIV medicines with U.S. taxpayer support, Trump responded, “Yes, I believe so strongly in that, and we’re going to lead the way.” Impact2016 notes, however, that Trump was not a fan of foreign assistance programs.

Trump said in his speech announcing his presidential candidacy that the United States should “stop sending foreign aid to countries that hate us” and to spend the funds domestically to “invest in our infrastructure . . . our tunnels, roads, bridges, and schools.” He has called development investments in Iraq and Afghanistan wasteful and that the funds should be used to “rebuild the United States.” When asked whether he would support military intervention on humanitarian grounds, Trump responded affirmatively, but added that it would depend on the national security implications for the United States and “how friendly they’ve been toward us.”

Trump’s running mate, Indiana Governor Mike Pence, also supported PEPFAR funding but had backed extremely conservative positions on domestic issues related to HIV, opioid abuse, and women’s reproductive health issues, leaving many in the health community to worry about his potential influence on global health policies in a Trump administration. Both as governor of Indiana and as a member of the House of Representatives, Pence consistently promoted very far-right policies on women’s reproductive rights, including a full ban on abortion in cases of demonstrated fetal abnormality. In Indiana, Pence supported a policy that would make it illegal to abort a fetus despite clear sonogram demonstration of microcephaly. As governor, Pence pushed health policies that are often credited with making Indiana the state with the fastest growing HIV incidence in the nation, driven by narcotics use among white middle-class residents of the state.

On other public health issues, the campaign offered some indications of what Trump’s policies might be like. As a candidate, Trump stated that vaccines may cause autism. Trump also said that illegal immigrants, predominantly from Mexico, were costing America $113 billion per year in public services, including hospitalization and health care—costs he vowed to eliminate by deporting eleven million immigrants now living in the United States.

He took a tough position on domestic healthcare, calling for complete elimination of the Patient Protection and Affordable Care Act (ACA), and its replacement with tax-deductible health savings accounts from which citizens could buy medical services in an open and competitive marketplace. Since enactment of the ACA, the GOP-controlled House has voted sixty-two times for its repeal, only to be blocked by the Senate. With this election, the House Republican majority is stronger and Trump supporters were elected to the Republican Senate majority. It seems reasonable to predict the ACA will be voted out of existence. The impact on Americans—especially those from demographics that voted for Trump, such as self-employed workers and middle-class entrepreneurs—will likely be devastating. Some thirteen million Americans now receive health insurance through state marketplace programs created under the ACA, and an estimated twenty million people were added to insurance or expanded Medicaid roles through the program, bring the uninsured rate in the United States to the lowest level in history. Neither President-Elect Trump nor the ACA opponents on Capitol Hill have ever explained how, precisely, these twenty million people will receive health care the day after the ACA is repealed.

Enrollment in health plans under the ACA commenced in October 2013, offering hope that the United States might attain universal health coverage (UHC). UHC is the primary underpinning of UN Sustainable Development Goal (SDG) number three goal: health for all. It will be difficult, perhaps even impossible, for the United States to provide credible leadership on UHC and the SDGs as the world watches twenty million Americans scrambling in desperation to pay for broken arms, trauma injury, cancer care, and childbirth.

The Obama administration has struggled to control health inflation, even in the controlled environment of the ACA. Eliminating government-run health programs (other than Medicare, veterans’ services, and some minimal Medicaid provisions) will put the economics of medicine in an open-market framework akin to automobile insurance or retail industries, but with one major difference that consistently drives inflation—consumers can live without car insurance or new tennis shoes, but if they are ailing, they cannot live without needed treatment.

Perhaps hinting at how he might hold down inevitable inflation in an open-market health system, Trump, in September 2015, roundly denounced pharmaceutical price gouging and attacked Martin Shkreli—a controversial hedge fund manager who took over a drug company and jacked up the price of an HIV-related medicine from $13.50 per pill to $750. Trump called Shkreli a “spoiled brat” and decried the price hike. The pharmaceutical industry knows that price scandals such as Shkreli’s and the EpiPen cost inflation have made it a hated, or certainly distrusted, business sector, so big pharma lobbyists have spent heavily in 2016 backing candidates in state and federal legislatures who hope to deregulate the Food and Drug Administration and eliminate drug price controls. While Trump has decried a “brat” he is not in favor of government-mandated price controls in any sector, including pharmaceuticals. Not surprisingly, the pharmaceutical sector surged on global stock markets the day after the election. One of the most important themes of global health for well over a decade has been access to affordable medicines, forming the basis of such dramatic global programs as PEPFAR, the Global Alliance for Vaccines and Immunizations (GAVI), Médecins Sans Frontières (MSF), and the Clinton Health Access Initiative (CHAI). All of these efforts could be imperiled by an unchecked pricing market for pharmaceuticals in the United States.

Additionally, during the 2014 Ebola epidemic, Trump opposed allowing ailing American health workers to come home from Liberia and Sierra Leone, tweeting (in all caps), “KEEP THEM OUT OF HERE!”

Overall, candidate Trump’s foreign policy positions hewed closely to three themes: destroy the self-declared Islamic State, reverse immigration to the United States, and promote U.S. economic growth through elimination of “bad” trade deals. When asked to provide his position on foreign aid spending, Trump was the only front-runner in the Republican primary who failed to do so.

In stark contrast, Hillary Clinton and running mate Tim Kaine coauthored a book,Stronger Together, detailing their policy positions, both foreign and domestic. Wherethe Trump campaign published 9,000 words of policy intentions, the Clinton campaign released 112,735—there is a great deal to peruse.

If one quote from the book summarizes the Clinton foreign policy doctrine, it is this: “America must not turn its back on the world. We must strengthen our alliances, not undermine them.”

The British journal Lancet created a website tracking the U.S. elections and their impact on global health: terrific detail can be found there, though in fairness to the Republicans it is clear the Lancet folks were not enamored of their candidate.

In addition to the fact that the Clinton-Kaine policy platform will now be cast aside with Trump’s victory, the much-maligned Clinton Foundation will suffer. It was created originally in 2001 to raise funds for construction of former President Clinton’s library but swiftly morphed into a platform for tackling development, poverty, and global health. The Clinton family has donated $22.5 million to the foundation since 2001, and though Chelsea Clinton—who has a DPhil in international relations from Oxford University—runs the Clinton Health Access Initiative, she takes no salary. In its annual reviews, Charity Navigator, a strictly nonpartisan watchdog group, consistently ranked the Clinton Foundation as one of the best in the world for transparency, financial accountability, low overhead, and quality of performance. In 2016, the foundation scored 94.74 percent, ahead of the International Rescue Committee, Catholic Relief Services, and Feed My Starving Children.

The foundation became a political liability during the campaign and Clinton’s opponents saw it as a conflict of interest, even claiming that it and allied groups used political leverage to pull money out of dubious foreign sources. The Clintons are unloadingelements of CHAI and the rest of the foundation at this time.

HOW BAD IS “BAD”?

Donald Trump did not win by a landslide, and the United States is arguably more deeply divided than at any time since the Vietnam War, perhaps even since the Civil War. Though Trump took the electoral college majority, Clinton won the popular vote and the margins of victory for Trump in many states were so narrow that the candidates switched leads multiple times during the night. At one point around 1 a.m. on the East Coast, Clinton led the vote count in New Hampshire by a mere 230 votes. Two days before the election, 60 Minutes conducted a focus group analysis of popular opinion, scientifically creating a sampling of the U.S. voting population. The broadcast results were grim—focus group members shouted at one another, swore, used deeply despairing language, and unanimously proclaimed the election mood to be “angry,” regardless of whom they planned to vote for. This anger will not dissipate, or diminish, any time soon.

Throughout the campaign, Clinton’s backers have characterized Trump as crazy, a woman-hater, and a Nazi. Conversely, some Trump supporters have called for Clinton’s jailing, even execution, or assassination. Six days before the election, Republican State Representative John Bennett saidHillary Clinton should immediately face a firing squad. Nine days before the election, Republican Richard Burr of North Carolina, who heads the Senate Intelligence Committee,commented on seeing the latest edition of the National Rifle Association’s magazine, saying, “It’s got a picture of Hillary Clinton on the front of it. I was a little bit shocked at that―it didn’t have a bullseye on it. But on the bottom right, it had everybody for federal office in this particular state that they should vote for. So let me assure you, there’s an army of support out there right now for our candidates.”

And on November 4, Trump warned, “If she were to win, it would create an unprecedented constitutional crisis. What a mess. I mean, we went through it with him [Bill Clinton] with the impeachment and the lies. Aren’t we tired of this stuff? She’s likely to be under investigation for a long time, concluding in a criminal trial, our president. America deserves a government that can go to work on day one.”

Trump has repeatedly vowed that he will send Hillary to prison once he is president, and his supporters often chanted, “Crooked Hillary!”

As fractured as the Republican Party is right now, it retained control of both the House and Senate in this election, and Trump is likely to swiftly appoint, and see approved, right-wing justices for the Supreme Court. But though there may be unity among Republican political leaders on such domestic issues as abortion and reducing the size of government, foreign policy is a source of strong differences. The Trump foreign policy agenda is characterized as isolationist, though he has vowed to destroy the Islamic State and build a wall along the Mexican border. Many Republicans favor a more interventionist foreign policy, in which the United States leads militarily—a perspective often touted by Senator John McCain of Arizona. Trade, nation-building, confrontations with Islam, relations with Russia and China, and the American role in development and UN activities—these are all points of debate among Republicans.

On the House side, Speaker Paul Ryan and his GOP majority can be expected to be wild, with some extremist members of the House going rogue, pushing legislation even Tea Party leader Ryan cannot support. Calls to “jail the Clintons” will likely resonate on Capitol Hill.

It would be easy to conclude that the picture is hopeless, making it impossible to expand or improve America’s role in global health, development, and foreign assistance.

THE GOOD NEWS IS…

Despite the most intense partisanship on Capitol Hill in living memory, a long list of advances were made in global health and development during the Obama administration. The American mobilization for Ebola response was substantial, and featured a Pentagon-led military effort—the first of its kind in U.S. history. The Obama administration beefed up the 2001 Global Health Security Initiative, and in early 2014, launched the Global Health Security Agenda (GHSA), which aims to bring nations worldwide up to the standards of disease surveillance and response stipulated in theInternational Health Regulations.

In hopes of cementing American commitment to GHSA, Obama issued an executive order on November 4, commanding twelve agencies ranging from the Department of Defense to the Office of Science and Technology Policy to formulate ways in which they can strengthen the agenda to “achieve a world safe and secure from infectious disease threats.”

Three months ago, Congress passed the Foreign Aid Transparency and Accountability Act, which was strongly promoted by the bipartisan Modernizing Foreign Assistance Network. Congress also passed the Global Food Security Act this summer, which promotes investment in small-scale agricultural development overseas. Last year, the Obama administration released its National Action Plan to Combat Antibiotic-Resistant Bacteria, which aims to both reduce overuse of antibiotics and promote research and development on new drugs and methods of microbial control—an effort backed by $1.2 billion. And despite deep opposition on Capitol Hill, Obama forged a series of dramatic climate change, fossil fuels reduction, and biodiversity conservation initiatives that will have longstanding impact.  These and dozens of other major initiatives were enacted and funded, despite partisan fights on Capitol Hill.

Of course, the opposing lesson was delivered by 251 days of delay in funding Zika programs. Congress refused President Obama’s February request for $1.9 billion for months, and then agreed to provide $1.1 billion on conditions that not a federal dime went to Planned Parenthood and that Confederate flags were permitted to be flown in military cemeteries. The standoff was only broken on September 29 by passage of a temporary national budget (known as a continuing resolution) that included the $1.1 billion, with no strings attached.

IT IS NOT JUST THE UNITED STATES, OF COURSE

Call it populism or cultural fear, or simply the ultimate shake-out from globalization—whatever the phrase, the trend is being felt all over the world. As noted economistNouriel Roubini puts it, the entire world is convulsing from post-2008 redistribution of wealth, which favored a small elite of ultra-rich at the expense of most of the world’s middle classes. “On a global scale,” Roubini writes, “this crosscutting current that is overturning the political establishment is compounded by the fact that emerging economies largely favor globalization since they have been its main winners. While inequality has worsened in advanced economies, on a global scale, the inequality gap has narrowed as trade and foreign investment have significantly improved living standards.”

As I wrote in June, following the Brexit vote, the British vote to depart the European Union had wide-ranging immediate impact on global health and development. Billions of pounds worth of remittances evaporated with the postelection collapse of the British pound, and great uncertainty is greeting all of the UK’s foreign assistance commitments. In May, before the Brexit vote, the pound was worth $1.46, but on November 7, it was down to $1.24—a disparity that has a profound impact on remittances from the United Kingdom to Africa and South Asia. The financial roller coaster is likely to continue to swing the British economy back and forth until Prime Minister Theresa May formally invokes Article 50, triggering withdrawal from the European Union. Happily—and perhaps surprisingly—the May government committed to strong support of the Global Fund to Fight AIDS, Tuberculosis, and Malaria in the fund’s recent replenishment drive, offering hope that an inward-looking United Kingdom will not completely walk away from the mission of stopping HIV, curing diseases, and raising life expectancies all over the world.

In his campaign, Donald Trump called himself “Mr. Brexit,” and welcomed support from its mastermind, Nigel Farage. The main point uniting Trump and Farage is distrust of government—a theme of the post-2008 global politics. Given public health is largely a government function, anger against government often puts health in harm’s way.

Collaboration is also challenged in an environment of trade protectionism. Whether it is Chinese popular opposition to imported Japanese goods, Bernie Sanders’s anti-Trans Pacific Partnership rhetoric, or Trump’s avowal to destroy the North American Free Trade Agreement (NAFTA), much of the populist anger is directed against economic and political pacts that seek to enhance trade and collaboration. In the post-Brexit climate, some of the strongest concern for the future has come from scientists, who fear that largemultinational research programs are imperiled.

Ultimately, the Trump administration will likely be challenged by the United States’ closest partners, such as Canada, Japan, the United Kingdom, and Germany, to retain G7 and G20 commitments, boost weak elements of the multilateral health and development system, fight climate change, and accelerate preparedness for outbreaks and bioterrorism. Trump vowed during his campaign to force the Europeans to “pay their fair share” for support from the North Atlantic Treaty Organization (NATO), and said that in the absence of stronger financing from Europe he, as president, would consider withdrawal from the alliance. Relations with states that have proved in the past to be critical partners in health and development will likely be tested during the Trump administration.

THE OTHER ELECTION: THE WORLD HEALTH ORGANIZATION

On Halloween WHO Director General Margaret Chan convened a special financing appeal to donors and country representatives. The gathering was attended by seventy-two member states and twenty international organizations, and aimed to raise funds to close the agency’s $500 million budget gap and fund new emergency reserves to combat outbreaks and address humanitarian crises.

For several hours, Chan and the WHO leadership described reforms achieved in response to stark criticism of  the WHO’s performance in the 2014–2015 Ebola epidemic, layoffs of some one thousand WHO employees to trim budget requirements, and a general determination to reform the institution. “We cannot take your generosity for granted—we have to produce results,” Chan told the assemblage. But she added, “You have asked us to do more, especially through the health emergencies program. At the same time, income from voluntary contributions has not increased. In the case of core voluntary contributions, income has decreased. The health emergencies program is the most important underfunded program, with only 56 percent of the required $485 million being funded.”

The WHO secretariat cited the World Health Emergencies program, informing participants, “The organization has been asked to do more, specifically through WHE, while income from voluntary contributions has not increased and core voluntary contributions income has actually decreased. While the WHE is the most important underfunded program (currently at 56 percent of requirements), a number of other programs are endangered by inadequate funding, such as the response to anti-microbial resistance, work on noncommunicable diseases, and HIV. Dr. Chan also highlighted that despite budgetary discipline, WHO continues to face a long-standing budgetary imbalance between voluntary and assessed contributions and she will ask the next World Health Assembly to approve an increase in assessed contributions. Finally, she announced that as an expression of its commitment to transparency and accountability, WHO will join the International Aid Transparency Initiative as of November 1, 2016.”

The meeting failed. As has been the case for three decades, a handful of wealthy nations (particularly the United Kingdom, which currently pays a $20,731,580 assessment, and Germany, which pays $29,677,840) supported raising the basic assessment nations pay, as dues, based on national gross domestic product (GDP) by 10 percent. And speaking on behalf of the sub-Saharan African nations, Zambia said Africa will happily pay an additional 10 percent assessment. (Zambia pays $32,520, so an additional 10 percent is only $3,250.)

The United States declined to commit, citing a congressional cap on all payments to the United Nations. (In addition to large voluntary donations to the WHO, the United States already pays the largest assessment to the agency, totaling $113,513,160 per year.) As has happened many times over the last few decades, most of the nations responded by either insisting the WHO should further trim its spending, or by claiming poverty and an inability to pay additional funds.

I monitored the proceedings and live-tweeted (@Laurie_Garrett) comments and observations. Overall, Chan appeared thoroughly exasperated by the end, having repeatedly told national leaders that it was unrealistic to expect her to cut the WHO budget further without eliminating major health programs. After all, most nations currently give a pittance to the WHO, and a 10 percent increase of a pittance equals a pittance plus a wee bit more. The enormous population of India, for example, tithes a mere $3,423,370 a year, but a 10 percent increase of $342,337 was deemed unaffordable by the country’s representative. Russia also pled poverty, citing falling oil prices, declining to pay a single increment above its current $14,344,690 a year. Once-generous Finland blamed world financial stagnation for its inability to commit a penny more to its current $2,118,120. Even China, with a 2016 GDP growth rate of 7 percent, requested further information on WHO reforms before it would agree to increase its support above the current $36,793,969 level. Only Norway, always a strong supporter of global health, ignored falling oil prices, agreeing to add $304,000 to its $3,040,000 assessment.

The German representative took other nations to task, saying, “The biggest overall risk for WHO is the uncertainty of long-term financing.” But few were swayed. Though the United Kingdom gave rhetorical support to raising basic assessments, it also demanded more improvements in WHO’s emergency outbreak and humanitarian response capacities. France hedged, also demanding further proof of epidemic response capacity, prompting Chan to note that she was only requesting $47 million in additional outbreak funds, and $474 million overall.

To put that WHO plea in perspective, here is the Washington Post’s breakdown on U.S. election campaign spending as of October 19:

Just as populism around the world seems to be driving demand that government do more for their people with fewer taxes and other revenues, so the nations, in turn, seem to have unrealistic expectations of the World Health Organization. They want the WHO to deliver on everything from standards of care for stage three melanoma to global mobilization for Zika response but do not want to pay for it. There is an unstated expectation that the United States, the United Kingdom, Norway, France, and Germany—as well as donors such as Bill Gates—will always come through in the clutch with emergency funds. Yet, Brexit signals retrenchment in the United Kingdom, Trump supporters are anti-United Nations by and large, France is less involved in issues outside Europe amid rising domestic support for far-right nationalists, and the once-popularAngela Merkel is struggling to maintain German support.

With this extremely challenging backdrop, six candidates are now running for Margaret Chan’s job in an unprecedented election procedure that I previously detailed. It is at once the most open and lively campaign in WHO history and the riskiest, as it will culminate in a secret ballot vote cast in May by 194 nations on a one country, one vote basis.

On November 1 and 2, the candidates faced country representatives and reporters in hours of questioning, aired live on the internet. They have all provided detailed manifestos for global health to the Lancet, and last week, five of the six (absent Ethiopia’s Tedros) faced tough questioning at the prestigious Chatham House inLondon. Certainly by the time the WHO executive board meets in January to pare the list down to three, the candidates’ views and qualifications will be well known. And by the time the nations gather for the May 2017 World Health Assembly and cast the final vote, there will be no excuses for ignorance regarding the individuals’ perspectives and leadership skills.

At Chatham House, the candidates cited as their primary qualifications:

Bustreo: “necessary character, capacity, and courage” to achieve the Sustainable Development Goals

Douste-Blazy: political skills to “tackle noncommunicable diseases and improve primary care”

Nabarro: ability to make the WHO “catalytic, convening, innovative, and evidence-based”

Nishtar: capacity to “pressure member states to realize its vision”

Szócska: years working in noncommunicable diseases

When asked, “What are the most important areas of reform for the WHO,” the candidates responded (paraphrased):

Douste-Blazy: There needs to be greater accountability between the director general and country officers with definitive global strategies for all divisions and regions of the WHO. The WHO needs to demonstrate impact relative to results and establish an independent advisory committee for emergency response.

Bustreo: More sustainable financing should be achieved by building on the number of donors and implementing innovative financing techniques, such as advance market commitments for vaccines. Right now, the WHO’s budget is equivalent to that of a pediatric hospital in Florence.  A major problem is that 80 percent of this budget is based on voluntary contributions that are earmarked. There needs to be a dialogue with each member state to figure out how to best grow assessed contributions. The WHO also needs to take a human-rights based approach to health and development using an evidence-based angle to improve health. There needs to be greater coherence between groups to advance this approach.

Szócska: There needs to be a performance management system and a rapid response team.

Nishtar: There needs to be greater accountability between the director general and regional officers. This could be achieved through mechanisms such as a coordination center that focuses on capacity building. While the WHO must focus on its core mandate, the SDGs present a new paradigm, linking with factors outside of health. The agency needs to align with rapid science and technology advancements, as well as embody the intersection between climate change, humanitarianism, and health.

Nabarro: The WHO needs to deliver the best results relative to the increasing number of global health threats. It is expected to do more with an ever-shrinking budget. It needs to be a curator of a managed network for world health, promoting partnership within a culture and movement of trust and effectiveness. There need to be safe spaces for interaction with the WHO based on partnership where no actor feels politically vulnerable.

AND FINALLY

Last year, I donated my research archive, dating to the 1980s, to the medical library of the University of California, San Francisco (UCSF). UCSF is, like all University of California campuses, struggling for funds, and seeking donations to cover its medical archive digitization process. I urged them to find resources to digitize one important element of my archive, the diary of Dr. Pierre Sureau, “La Decouverte Du Virus Ebola: L’epidemie De Yambuku, Zaire, Septembre-Octobre 1976.” It is now preserved at the UCSF archives and can be found in carton number ninety of my papers.

Sureau was a remarkable scientist at the Pasteur Institute in Paris. I had the honor of visiting him in the early 1990s when he was waging a courageous personal battle with cancer. Because he knew his illness was fatal, Sureau gave me his personal diary of the 1976 Ebola epidemic in Zaire, which describes many details of the outbreak that have been confused in the subsequent historical record. I drew heavily from the diary for The Coming Plague, published in 1994. There is a remarkable passage in which Sureau mentions his struggle in primitive facilities in Kinshasa to find a way to isolate the virus from a Zaire blood sample and study it under a microscope. He has no protective gear—none of the trappings of personal protection all Ebola researchers don today. He develops an immunofluorescence assay and when it finally works and he can see the glowing virally infected cells under his light microscope, he exclaims, “Les etoiles!” (the stars). I am delighted that UCSF now has the marvelous diary available for all to see.

We have been very busy of late in our global health efforts. I participated in a three-day summit on synthetic biology and dual-use research of concern, convened in Monterey, California, by the Middlebury Institute of International Studies, to advise government agencies from the United States and several other countries regarding biodefense in the age of CRISPR-Cas9.

I was pleased to meet with Council on Foreign Relations members in Atlanta, Miami, and San Francisco to discuss the Zika virus threat in September and October. I was also asked to address or participate in a number of activities surrounding the opening of the UN General Assembly in late September and its special session on combating antibiotic resistance. And I delivered keynote speeches recently to the University of Maryland’s School of Public Health, the American Health Information Management Association’s annual convention, and the gathering of the Society of International Business Fellows.

Recent publications include:

“The 18 Essential Foreign-Policy Questions Clinton and Trump Need to Answer” inForeign Policy

“Congress’ Cynical Zika Game Threatens all Americans” for CNN

“Antibiotic Resistant Bacteria and the World’s Peril” in Scientific American

“Is Zika Just the Beginning?” aired on StarTalk Radio with Neil deGrasse Tyson

As always, we will endeavor to keep you informed on these and other pressing issues in global health.

Laurie Garrett

Laurie Garrett
Senior Fellow for Global Health
Council on Foreign Relations

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