Surprise us, Mr Trump
Authors: None The Lancet Global Health
Journal: The Lancet Global Health (2017)

The halls of global health diplomacy were buzzing last month, as the WHO Executive Board voted on Jan 25 to narrow the field to three candidates for the position of WHO Director-General. The USA is part of the current 34-member board and a vital member and funder for WHO, one that provides close to a quarter of the total membership dues and about a third of voluntary contributions to the agency's budget—at least for now. Two legislative bills introduced in early January in the US House of Representatives and Senate are seeking to withhold funds from the UN and open a way for the USA to leave the global body, and therefore withdraw membership of WHO. Those bills, some versions of which have been introduced yearly since 1997 to no avail, are nowhere near a vote in Congress but given the current political context in the USA, vigilance is imperative. Indeed these are tumultuous times for the global health community. The US government, the largest funder and implementer of global health programmes worldwide, is going rogue. Donald Trump's first weeks as President have been rocky: marches tantamount to civil unrest have shown the level of discontent with his election around the world, most of his cabinet is still unconfirmed (including, as we go to print, his Health and Human Services Secretary), and his executive orders have been met with uproar and legal action. The reinstatement and extension of the Mexico City policy, which blocks federal funding for NGOs advocating for or providing abortion services, is one of his most concrete and far-reaching actions so far, one with major negative impact for women and children around the word. We now anxiously wait to see what other bomb is going to land on global development efforts. We know few things about Trump's position on health. His national agenda, which already includes a repeal of the Affordable Care Act (ACA), is slowly taking shape, but he has given few clues about his position on health diplomacy and he has not directly mentioned global health issues, aside from a rhetorical and slightly mystifying statement in his inauguration speech, where he positioned the USA as standing “at the birth of a new millennium, ready to […] free the Earth from the miseries of disease […]” Trump admittedly likes to be unpredictable, so it is impossible to gauge what he is going to do. One thing we know is that he is a businessman, so while we cannot expect Trump to exhibit the skills of a diplomat or a policy-maker, we could rightfully scrutinise the sharpness of his business acumen. As Trump defines a strategy for his priority issues, it would be good business practice for him to consider existing strengths and weaknesses, opportunities and threats in the national and global environments—the basic SWOT analysis. For instance, security figures high on his agenda: it is his main argument for instating an objectionable ban on travellers from seven Muslim countries entering the USA in late January. In this day and age, it would be aberrant to ignore that national security must include a consideration of health security on a global scale. Borders that are closed to citizens of “unfriendly” countries are still permeable to communicable diseases, particularly in a public health environment weakened by a Trump-supported anti-vaccination movement and a diminished ACA-driven prevention programme. It would make sense, therefore, that Trump should rely on existing opportunities and strengths and provide continuity to programmes that have promoted the removal of the threats at the source, through adequate financing for the Global Health Security Agenda and bilateral programmes like the President's Emergency Plan for AIDS Relief or the President's Malaria Initiative, which have been described as successful and cost-effective. And where weaknesses are found—Trump for instance has a clearly negative view of the UN and its agencies—the role of an enlightened business leader would be to remediate these by building on existing strengths (Trump has tweeted that the UN has “great potential”), supporting reform, or boosting the existing capacity for innovation in the USA to find solutions. Taking over a business is one thing, but running it is another, just like winning an election is one step removed from leading a government. If we try hard enough, we could give Trump the benefit of the doubt: after all, he has no experience in policy-making and seems unfamiliar with global health issues. But some things make more business sense than others, so focusing our efforts on demonstrating how sound an investment in global health would be seems practical. Let us hope he truly is unpredictable and surprises us—in a good way.