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Health is on the Ballot This November-Global Health

The 2024 US presidential election will have a vast effect on the health and lives of US residents as well as on many people abroad. The two major candidates hold markedly different views and agendas across global health policy issues.

COVID-19 Pandemic

The actions taken by the Trump Administration during the COVID-19 pandemic can most charitably be described as a mixed bag. He advocated unscientific treatments like the antiparasitic medication Ivermectin against the advice of the Food and Drug Administration (FDA). He held frequent “super spreader” campaign events against the advice of Dr. Tony Fauci, our preeminent infectious disease expert.

Trump announced that the US was withdrawing from the World Health Organization (WHO) in May 2020, based on claims that were false, misleading, and unsubstantiated. The Biden Administration immediately reestablished our membership in WHO in 2021.

On the other hand, the Trump Administration allocated $18 billion to Operation Warp Speed to speed up the development of highly effective COVID-19 vaccines that the FDA authorized within a year. In pharmaceutical terms that is warp speed. Despite a lot of pushback from sceptics, eventually enough people were vaccinated to allow us to come out of lockdown.

Isolation is not Insulation

U.S. foreign assistance makes up less than 1% of our national budget and includes support for HIV/AIDS, tuberculosis (TB), malaria, family planning, neglected tropical diseases, maternal and child health. This funding not only saves lives, it also contributes to global political and economic security and stability. President Trump’s budget request for fiscal year (FY) 2018 called for reducing foreign assistance for global health down from $8.5 billion to $6.5 billion. That is a 24% reduction in spending.

Biden’s budget request for FY2025 includes $9.8 billion for global health. The administration is negotiating with WHO to form a WHO Pandemic Agreement with 194 member states that would address some of the gaps in the COVID-19 response.

At the United Nations General Assembly (UN) meeting in late September, philanthropist Bill Gates reported that because of advances in nutrition and access to vaccines in low-income countries, deaths of children under five years old have dropped from 10 million down to 5 million per year since the turn of the century. The UN’s goals are to cut that number in half again by 2030.

Global access to vaccines initiative (GAVI)

Now, Gavi is preparing to support countries to recover from lost progress on routine immunization due to the COVID-19 pandemic. Gavi is gearing up to deepen efforts to reach all children who have not received any doses of vaccines, introducing new life-saving malaria vaccines, and supports the sustainable growth of vaccine manufacturing in Africa. 

Why build vaccine manufacturing in Africa?

While that might sound like the set up to a why Willie Sutton robbed banks joke, Gavi has good reason to avoid counting on biotech companies like Moderna to supply vaccines.

There’s also a horrific and, frankly, racist narrative that countries in Africa won’t be able to use the vaccine. Now that’s certainly true when you just dump a lot of leftover vaccines. I know one small area in Africa that got seven different vaccines with short expiration dates, no planning, no predictable supply. So yeah, in that situation you’ll have problems. Dr. Tom Freiden, President and CEO of Resolve to Save Lives; Director of the Center for Disease Control (CDC) in the Obama Administration.

Over one billion dollars of taxpayer money and the expertise of the National Institute of Allergy and Infectious Disease (NIAID) scientists allowed Moderna to develop it’s COVID-19 vaccine. Then they refused to share that technology with the rest of the world. It’s morally inexcusable, but they have come up with excuses, all of which are untrue.

“We can’t transfer technology because we don’t have enough staff.” They have chosen not to have enough staff.

“We can’t transfer technology because it takes 12-18 months to scale up.” It took one partner of theirs, Lanza, between three and six months, depending on how you count it.

“Africa can’t use the vaccine effectively.” Africans have much less vaccine hesitancy than people in the US and most Western countries. They have a greater ability to run vaccination campaigns because it is something they do regularly.

To be sure, Moderna, which started up in 2010, has always been a bit sleazy. In February 2016, a Nature article criticized Moderna for not publishing any peer-reviewed articles on its technology, unlike most emerging and established biotech companies. In May 2020, Moncef Slaoui resigned from the board of directors of the company to take the lead on “Operation Warp Speed” during the Trump Administration. Slaui continued to hold more than $10 million in stock options while the federal government invested $483 million to assist Moderna in vaccine trials.

Aside from the intuitive pleasure derived from bending the arc of the moral universe by lifting disease burden, there is the added benefit of creating more political and economic stability.

Issues on the Table Right Now

COVID-19 has revealed inequalities in the world's healthcare delivery system. It did not create them. The need is critical and the world is responding.

Polio vaccines are being distributed in Gaza. It is not enough, but it is a start.

Two new malaria vaccines are being rolled out.  As the parasite becomes more resistant to anti-malarial drugs and mosquitos develop resistance to pesticides, prevention is our best hope for saving lives. Currently, our best option for prevention in a timely manner is vaccination.

Gavi also helped introduce new vaccines to fight two of the most deadly diseases for kids: pneumonia and diarrhea. As mentioned previously, two new vaccines to fight malaria that are being used widely in countries like Ghana. Malaria kills more than 600,000 people a year, mostly children in Africa. Gavi is preparing to support over 20 African countries to introduce these ground-breaking vaccines.

The US took a big step in helping put this plan into action. At the June 2024 Gavi pre-replenishment meeting in Paris, the U.S. pledged at least $1.58 billion for Gavi over the next five years. This is an excellent way to ensure the project has funding stability. That is critical to achieve goals beyond an immediate crisis.

A bipartisan Gavi resolution (H.Res.1286 / S.Res.684) provides a multi-year commitment to Gavi to ensure access to lifesaving vaccines and work towards ending preventable child and maternal deaths.

My Take:

Given that the Trump Administration withdrew from WHO early in the COVID pandemic when it became clear that it was not going to be "gone by Easter". Neither the WHO Pandemic Agreement nor Gavi will receive robust funding in a second Trump term.

Global health is not a zero-sum game. The return on investment in life expectancy, productivity, and stability with adequate funding on global health is enormous. In many ways Health is on the Ballot this November.

[docmerry]

Health is on the Ballot in November-Reproductive Health

REPRODUCTIVE HEALTH

Perhaps you have been marooned on an uninhabited island for the past decade, in which case, let me catch you up. One of the promises that Trump fulfilled during his time in office, with an assist from Republican Senate Leader Mitch McConnell, was to appoint justices to the Supreme Court of the United States (SCOTUS) that would overturn Roe v Wade. The appointments of justices Gorsuch, Kavenaugh, and Coney Barret gave conservatives a supermajority on the bench,

In Dobbs v. Jackson Women's Health Organization (2022), SCOTUS overturned Roe v. Wade (1973) and Planned Parenthood v. Casey (1992).decision in 2022 overturned what had been the law of the land for close to 50 years. Since then, 21 states have passed laws or reinstituted “trigger laws” that were on the books prior to 1973 that restricted or prohibitted abortion. Stick a pin in that.

Justices Gorsuch, Kavanaugh, and Coney Barret were recommended by the Heritage Foundation (Heritage), which is a conservative think tank that began in 1973 and has been active in Republican politics since the Reagan administration.

Heritage is the publisher of "Mandate for Leakership: The Conservative Promise" aka Project 25, a conservative playbook for the next Republican administration. It includes utilizing the 1873 Comstock Act, an anti-vice law that specifically prohibits the mailing of items related to abortion or birth control. Project 2025 suggests that mifepristone, a drug used in medical abortions, should not be mailed to patients under any circumstances. Additionally, this law from the nineteenth century could prevent the mailing of devices used in surgical abortion.

SCOTUS heard two cases in the latest term on abortion. FDA vs Alliance for Hippocratic Medicine was a case brought by Texas physicians that challenged the approval of mifepristone. In a unanimous decision, that case was thrown out because the doctors were found to lack standing to bring the suit.

In the notable case of Moyle v. United States, consolidated with United States v Idaho, the central issue was whether the federal Emergency Medical Treatment and Labor Act (EMTALA), which mandates hospitals to provide stabilizing treatment, including but not limitted to emergency abortions, preempts state law in Idaho and five other states that restrict abortion. Once again the court decided not to decide and sent the case back to the lower courts. The justices were divided, with Justices Alito and Thomas suggesting that states may prioritize the fetus's health over the woman's. Currently, women in Idaho and five other states can obtain an emergency abortion.

Justices Alito and Thomas are both in their seventies. If Trump were to win the election in November, it is anticipated that they would retire during his term, potentially solidifying a conservative supermajority for an extended period.

Just as men’s health is about more than just erectile dysfunction, reproductive health is about more than just abortions. Bills have been introduced in the House and the Senate that address In-vitro fertilization (IVF) and access to contraception. The future actions of those who enforce moral standards remain uncertain.

Across the aisle, Democratic Vice-Presidential candidate Tim Walz signed a law that "codified Roe," granting the right to abortion access in Minnesota's constitution. President Biden and VP Harris have considered similar national measures, but without eliminating the Senate filibuster, that would be a heavy lift in Congress.

Regarding the broader strategy, it may not be detrimental. Ruth Bader Ginsburg posited that if Roe v. Wade hadn't made abortion legal nationwide in one sweeping decision, states might have individually repealed anti-abortion laws gradually, similar to the recent trend of states legalizing recreational marijuana.

We don’t live in that universe. We live in this one where reproductive health is on the ballot in November.

[docmerry]

Health is on the ballot in November

I’ve seen the gurney from both sides now (with apologies to Joni Mitchell)

In the early eighties, I studied Naturopathic Medicine at Bastyr University. A beloved teacher of mine often joked, "If you ever get diagnosed with cancer, don't call your doctor, call your travel agent." That line always got a laugh. Then, I was diagnosed with cancer.

Thirty years later, as I was being wheeled into the operating room, my wonderful surgeon, Joanie Hope, leaned over the gurney and reassured me, "I'm going to take good care of you."

"I know you will," I replied.

That’s what medicine is supposed to be about. A trusting relationship between patient and provider. At no point should the grinding stress of financial ruin be layered on top of the hard work of not dying.

In my practice, I've often told patients, "I can't dictate what you can afford, but this is what you need." When I was a student, I didn't realize the significant impact cost would have on deciding which tests and procedures, even routine ones, to order. Like many in the medical field, my primary desire was to assist people in line with my training.

If nothing else, COVID-19 has shown that our healthcare providers are exceptional, with nurses donning garbage bags, refrigerator trucks filled with bodies, and a sense of building the plane while flying it. They have indeed risen to the occasion.

It also revealed a couple of glaring flaws. Not everyone has access to care, despite the Affordable Care Act, and it is unbelievably expensive when compared to the rest of the world

The United States held the unfortunate record for the highest number of Covid cases and deaths globally.       

May 2021

COVID hit us hard. But did it hit hard enough to convince us to take some strong medicine?

Even though the US spends more, a lot more, on healthcare than any other country, we are not a nation of healthy people.

I cannot go through the whole "Medicine according to Marx " lecture here. For now, I will borrow the words of Yashaswini Singh, a Healthcare economist at Johns Hopkins University.

"There has been a longstanding tension between medicine as a profession and healthcare as a business. The key concern has always been that business obligations to shareholders might not align with physicians' obligations to patients"

Healthcare expenditures, measured as a percentage of GDP (the total value of goods and services produced annually), have risen from 5% in 1960 to 17.3% in 2022, according to Vankar. While I am not an economist, this represents a significant sum of money, predominantly managed by private equity funds, hedge fund managers, and pharmacy benefit managers. One might wonder, what could possibly go wrong?

Financial crisis of 2008-2009

HEALTH CARE ACCESS

The Patient Protection and Affordable Care Act of 2010, also known as the ACA or Obamacare, has made strides in addressing the issue of access to health insurance for those who cannot afford it. The strategy includes expanding Medicaid—a move adopted by most but not all states—establishing a marketplace for individual health insurance, and offering subsidies to reduce the cost of policies. The uninsured rate decreased from 17.8% in 2010 to 8% in 2022, according to Tolbert, marking a significant benefit for the insurance industry.

The Families First Coronavirus Response Act, enacted during the Trump administration, mandated continuous Medicaid enrollment throughout the COVID-19 public health emergency. Upon its expiration at the end of March 2023, an estimated 25 million individuals, including a significant number of children, were disenrolled from health coverage, according to KFF.

Under the Biden administration, the American Rescue Plan and the Inflation Reduction Act have extended ACA subsidies until 2025, offering an average annual saving of $800 to 13 million people. (Dept. of Health and Social Services)

MAGA and Republican members of congress

Currently, the campaign is light on details, but it's known that in the summer of 2017, Congressional Republicans attempted unsuccessfully to dismantle Obamacare. This time around, Trump isn't focusing on repeal and replace rhetoric, but he claims to know how to fix our healthcare problems-because of course he does.

Project 2025 is an initiative developed by the conservative Heritage Foundation, aimed at influencing a new, like-minded President. Despite Trump's denial of any knowledge of this play book, many of the over 400 scholars and experts involved in Project 2025 have ties to his administration. The healthcare aspects focus predominantly on contentious cultural issues such as abortion, gender-affirming care, and fetal tissue research. It also proposes extensive changes to agencies like Health & Human Services, National Institutes of Health, and Centers for Disease Control and Prevention. Further details will be covered in my upcoming issue on reproductive health.

In March of this year, the budget proposed by the Republican Study Committee in the House of Representatives, if enacted, would have cut $4.5 trillion from the Affordable Care Act, Medicaid, and the Children's Health Insurance Program (CHIP). Additionally, it would have removed certain protections for consumers, the elderly, and individuals with disabilities. (White House briefing 3/26/2024)

Biden/Harris

The Biden administration has primarily concentrated on managing the costs of prescription drugs such as insulin for Medicare recipients. While this approach may be beneficial in the short term and on a superficial level, it does not address the core issue. To effectively tackle the problem, the administration might need to heed the counsel of Republican Teddy Roosevelt to "speak softly and carry a big stick." The negative impact of banks being "too big to fail" is well-known, but the consequences are far more severe when hospital chains reach such a magnitude. This principle also extends to medical appliance manufacturers, Big Pharma, and hospitals that claim non-profit status.

During her tenure as California's Attorney General, Harris was an active opponent of healthcare consolidation for seven years. It is anticipated that she will seek methods to restrict private equity ownership of healthcare facilities, prioritizing public health over shareholder interests.

During her 2020 campaign for the Democratic presidential nomination, Senator Harris endorsed a "Medicare for all" plan among several proposals. Subsequently, she has aligned with the Biden Administration's strategy to expand upon Affordable Care Act. The progressive members of the caucus are expected to persist in their strong advocacy for a single-payer option.

My Take:

It has been seven years, six months and twenty-one days since I was wheeled into that operating room and had that exchange with my doctor/friend Joanie Hope, and to date I have no evidence of disease. I am lucky. I know that.

I believe everyone deserves equal access to quality care and expertise. That's why I pay attention to what political candidates promise, but I place greater importance on their actions. Health is on the ballot.

Bibliography

DHHS, Inflation Reduction Act Toolkit. retrieved 9/2/2024

KFF.otg, Medicaid Enrollment and unwinding tracker, (8/24/2024) retrieved 9/2/2025

Tolbert J, Sing R, Drake P, (5/28/2024), The uninsured population and health coverage. KFF.org retrieved 9/2/2024

Vankar, Preet (2/16/2023), US Health expenditures as percent of GDP 1960-1922, statista. retrieved 9/1/2024.

Whitehouse.gov/briefing-room/statement-releases/2024/03/26/fact-sheet-us-house-republicans-release budget-to-increase-health-care-costs. retrieved 9/2/2024