Anti-RFK article in global development publication DEVEX reveals much about DHHS' international involvement (that might benefit from change)

Will RFK Jr. ‘go wild’ on global health?

https://www.devex.com/news/will-rfk-jr-go-wild-on-global-health-108837

Much of the concern with Robert Francis Kennedy Jr.’s nomination to lead the U.S. Health Department centers on how his views might affect U.S. health policy. Many HHS agencies work globally, so there’s a lot at stake in global health.

By Jenny Lei Ravelo // 04 December 2024

Closeup portrait of Robert Francis Kennedy, Jr. speaking into microphones behind a podium in Las Vegas, Nevada, USA, on July 12, 2024. Photo by: Alamy

When incoming United States President Donald Trump announced his pick to lead the Department of Health and Human Services, or HHS, there was palpable concern in the health community. Robert Francis Kennedy Jr., better known as RFK Jr., has a history of believing in and promoting what many would consider junk science, and funding programs and activities that promote misinformation and fuel conspiracy theories.

He has linked vaccines to autism, called the COVID-19 vaccines deadly, funded an anti-vaccine nonprofit, and called an anti-vaccine advocate a “hero.” He also cast doubts on the long-established fact that HIV causes AIDS, touting false claims by AIDS denialists.

Much of the concern around RFK Jr. focuses on how he might affect health policy domestically. But many offices and agencies within HHS also work globally, meaning there is a lot at stake for the global health community.

Global health leaders Devex spoke to said the leadership changes may pose challenges for global health and science, but how exactly remains the subject of speculation. Some had grim forecasts on U.S. leadership on global health, while others were more cautious in their comments.

“It’s clear that the election result marked a change in direction and policy, but it’s too early to say at this stage how this will shape up with regards to pandemic preparedness,” the Coalition for Epidemic Preparedness Innovations, or CEPI, CEO Richard Hatchett wrote to Devex. Hatchett previously worked in senior roles at HHS during the administrations of former U.S. Presidents George W. Bush and Barack Obama. Before CEPI, he was acting director of the U.S. Biomedical Advanced Research and Development Authority, or BARDA, which is also part of HHS.

“While there have always been legitimate differences of opinion between administrations about specific approaches and priorities, health security has long been a matter of common concern that rises above party politics, and I would anticipate that to be the case going forward,” he added.

Lawrence Gostin, O’Neill Institute chair in global health law at Georgetown University and an established expert on U.S. and global health law and policies, had a bleaker prognosis.

“I think that we’re likely to see a wholesale pullback and restructuring of America’s global health presence around the world, and that will affect … United States diplomacy, particularly on the pandemic agreement, its relationship with the World Health Organization and other U.N. agencies, and then funding and partnerships,” he said.

Before the election, Trump said he would let RFK Jr. “go wild on health,” food, and medicines, on the campaign trail. “It’s hard for me to see him pulling back and trying to stop RFK from doing whatever crazy things he will do,” Gostin said.

HHS and global health work

The job Trump is entrusting to RFK Jr. is massive. HHS has a budget of around $1.8 trillion, and more than 80,000 employees across the U.S. and globally. Several of its agencies are involved in shaping international frameworks, funding health research, and supporting disease surveillance and emergency response in low- and middle-income countries.

Loyce Pace, assistant secretary in the global affairs office at HHS, described how the department engages globally through health diplomacy, protecting health security and advancing health equity, in an interview with Devex.

A key aspect of its work is engaging with WHO and its governing bodies in Geneva and other regional offices, where they discuss important health policies, and assist WHO on its work. A recent example is in developing WHO’s new program of work, which was approved by the World Health Assembly — WHO’s ultimate decision body — last May and whose implementation starts in 2025. They also engage with other health leaders in high-level forums such as the G7 and G20 where some of the world’s biggest economies discuss pressing global challenges.

HHS also helps to shape international legal frameworks. One of its big wins this year was getting WHA to agree to amendments to the International Health Regulations, the legally binding international instrument that defines countries’ rights and obligations during public health emergencies.

The department also helps countries build emergency operation centers, laboratory and surveillance systems, as well as trains health professionals so they can better respond to health threats and emergencies — and stop them before they escalate and spread to the United States and other countries — through the U.S. Centers for Disease Control and Prevention, or CDC. It also aids in outbreak investigations, as was the case during the Ebola outbreak in Uganda in late 2022, or determining the source of human H5N1 cases in Cambodia in 2023.

CDC is one of the operating divisions of HHS. It has over 60 offices in almost every region of the world and helps implement many U.S. and international global health initiatives, such as the U.S. President’s Emergency Plan for AIDS Relief, or PEPFAR; the U.S. President’s Malaria Initiative, or PMI; the Global Polio Eradication Initiative, or GPEI; and the Global Health Security Agenda, or GHSA.

The National Institutes of Health, or NIH, is another massive organization within HHS. It is the largest single funder of global health research and development globally. An analysis by the Global Health Technologies Coalition in March found NIH investments had contributed to developing 46 health technologies for neglected and other emerging diseases since 1999, as well as 217 global health technologies in late-stage clinical development. Some of the products now on the market that benefitted from NIH support include the drug pretomanid for the treatment of drug-resistant tuberculosis, and the long-acting HIV prevention injectable, cabotegravir.

The U.S. Centers for Disease Control and Prevention works in about 60 countries, and most of its global funding goes to local partners. CDC’s Kevin Cain talks about the agency's local approach — and what it means for the COVID-19 response.

NIH’s Fogarty International Center also helps in strengthening international research capacity. It has provided research training to nearly 8,500 U.S. and foreign scientists working in low- and middle-income countries. Many of these scientists have gone on to lead government-level responses to disease outbreaks such as Ebola, Zika, and COVID-19.

The department also facilitated the donations of vaccines for COVID-19 as well as vaccines for mpox in the current outbreak affecting several African countries. Pace said they’re also making sure that they’re addressing the issues of communities most affected by HIV and AIDS, such as LGBTQ+ communities as well as women and girls.

Hard-fought wins at stake

There are concerns however that some of HHS’ big wins could be lost in the next administration. This includes the IHR amendments, which HHS spearheaded.

The amendments include new obligations for countries to inform WHO of health events in a timely manner, and for WHO to share information about a health event that has the potential to be of international concern, even if the country where it is happening does not want to collaborate with WHO. They come into force on Sept. 19, 2025, except for countries that decide to reject them. (My mistake; I was thinking of the timeline to reject the amendments—Sept. is correct—Nass)

If Trump withdraws from WHO again, it would mean the U.S. is no longer bound by IHR, experts said. RFK Jr., when he was running for U.S. president, opposed the amendments and said he would reject them if he was president.

States have until July 2025 to reject or make reservations on the amendments.

While a state party could opt out of IHR, “I think they would be quite unpopular if that were the case,” Pace said. “If the U.S. stops sharing information, (the US does not share information as required, and that is why WHO and international scientists have criticized the US for withholding information on bird flu—Nass) then what’s to say other countries won’t stop sharing that information. If the U.S. stops engaging in research exchanges, what’s to say these other countries … who also have access to some of those research and innovations, won’t do the same.” (She fails to note the reservations the US already issued in 2006 to avoid being bound by requirements of the IHR—Nass)

“It’s our hope that the U.S. will continue to show leadership and partnership in this space, particularly to protect the American people,” she added.

RFK Jr. also made stopping the pandemic treaty part of his fundraising campaign for president, saying: “If you want a president who will stop the WHO treaty and stand with Americans, please donate whatever you can now.” Trump also said under his next administration the treaty would be “immediately terminated.”

There was already pushback against a pandemic agreement in the current U.S. Congress. Under Trump and a Republican-majority Congress, some experts said there is “zero chance” it will be ratified in the U.S.

While countries can still push through with a pandemic agreement without U.S. participation, experts said there will be significant implications, for example, on sharing medical countermeasures such as vaccines with the rest of the world.

Negotiations continue in Geneva and aren’t expected to be taken up by WHA until May next year. Whether a new administration means a new set of negotiators, Pace said she can’t speak to “what happens when we're not in these chairs”. But she said the current U.S. negotiating team is continuing to work on outstanding issues.

Potential impact on international health entities

One organization that could be significantly affected by the leadership changes in the U.S. is WHO. Trump has said on the campaign trail that he would withdraw from WHO if he becomes president. And RFK Jr. has accused it of being “taken over by global elites and foreign powers that don’t share America’s best interests.”

WHO said it has not received any indication of a withdrawal yet from the incoming U.S. administration, but for some experts it looks more like a matter of when not if.

Whether that withdrawal happens on day one of Trump’s presidency or later is unknown, but there will be an impact on both the U.S. and WHO, said Josh Michaud, associate director for global health at the Kaiser Family Foundation.

Although a withdrawal would take at least one year, WHO could lose significant funding if the U.S. pulls out of its membership. The U.S. is WHO’s biggest country donor, contributing almost 16% of the agency’s revenue between 2022-2023. WHO has recently succeeded in raising pledges and commitments to half of its fundraising target to implement its work for the next four years. And while they’ve not factored in U.S. contributions in that effort, it could still lose U.S. assessed contributions, which stood at over $100 million in 2024.

“You can soften the blow by making certain changes, or other donors might be able to step in and fill in some of the hole … but it’s going to be hard to completely adjust to the absence of the U.S.,” Michaud said.

WHO could also lose some expertise. HHS has staff seconded to WHO, providing their technical expertise to the organization’s work.

On the other hand, if the U.S. removes itself from engaging with the organization, “that could come back to bite the United States if there was a delay in identifying a new outbreak that could eventually come to the United States,” Michaud said. The U.S. would also lose its place at the decision-making table when it comes to setting health policies and negotiating health agreements.

RFK Jr. hasn’t said much about global health institutions and programs, such as Gavi, the Vaccine Alliance and PEPFAR — but there are concerns that his views on vaccine safety and HIV may extend to these entities.

RFK Jr. cannot determine or cut funding for these entities — that’s the job of the U.S. Congress. But he could position himself as a critic or raise concerns about some of these programs, Michaud said.

Trump and his allies could cut funding to programs already authorized by Congress through impoundment — something he tried to use to withhold funding to Ukraine during his first term — but Michaud said they will have to go through a huge legal hurdle.

“I don’t know if that’s going to happen at all or anytime soon, but that’s certainly a discussion that’s being had in Washington right now,” he said.

Concerns about funding cuts

Just before his nomination to lead HHS, RFK Jr. said he would replace 600 NIH employees.

“The rhetoric about cutting staff concerns us, but I hope through RFK Jr.’s confirmation process, those NIH-supportive Senators can articulate — and make the case that, if he is approved — a strong and capable agency workforce is essential to RFK Jr.’s stated goals of making America healthy,” wrote Alex Long, Global Health Technology Coalition U.S. policy and advocacy officer.

But even before RFK Jr. takes office, Republican lawmakers have already started pushing for reforms within NIH. A proposal in June from the House Committee on Energy and Commerce includes a restructuring of NIH, increased oversight on its grants, and a reorienting of its mission to focus on “the whole individual and all populations across the entire lifespan” instead of certain demographics or diseases.

Long said it’s unlikely that policymakers would be able to advance any legislative package for NIH reform in the present Congress, which ends in January. But with a Republican trifecta in power — the White House and a Republican majority House of Representatives and Senate — he said House and Senate Republicans “are poised to take on a likely long NIH reform process” in the next Congress.

It won’t be the first time reforms have been introduced within NIH. But Long said, “We need to ensure that reforms proposed on the Hill and by incoming agency leaders don’t put global health research on the back burner when it has never been clearer that this research saves lives, is a solid investment with significant return on investment, and benefits Americans.”

Amid reform discussions and critics of certain NIH institutes, annual NIH funding has remained relatively steady, which shows bipartisan understanding of the value of NIH’s work, he said.

Republicans have also been pushing to cut the CDC’s budget. Gostin is concerned the cuts may fall on global health work. Most of what RFK Jr. has said to date is about “Make America Healthy Again” — from combatting chronic diseases in the U.S. to removing harmful chemicals from American food. However, he hasn’t said much about global health work, and Gostin said RFK Jr. and the other Trump health nominees haven’t much track record or experience working in global health.

‘Focus on the mission’

Pace is one of the many political appointees under the Biden-Harris administration and is likely to leave once Trump takes over next year.

She’s been proud of the work she’s done with her team at the global affairs office and believes that work will continue amid leadership changes. Many people within her team have been there for a decade or more.

There’s “still a lot to be done in global public health,” and she continues to have conversations every day about what’s happening across the world, from outbreaks to “ongoing assaults on rights and protections that can affect people’s ability to … attain the highest standard of health and well-being,” she said.

It’s unclear where she’s headed next, but she said she remains committed to fighting and protecting the progress her team has made on global public health.

“It’s hard to get this work done. It seems increasingly harder to do this work because of conflict and climate and other controversies … that can affect what it is we do and how successfully we can do it. But we have seen these successes despite all of those things,” she said.

She advised her successor to continue to “focus on the mission.”

“I’d also welcome that person reaching out to me,” she added. “They would be joining an incredible family of global health leaders and champions, keepers of the flame, if you will. And so I think really taking that responsibility to heart, and knowing how critical it is for the U.S. to just continue playing the credible and successful role that we have in this space will not only serve this office and this department … [the] various agencies and obviously our policymakers, but it’ll serve our people.”