Health 202: Tillerson's rhetoric didn't match reality on global health

Wednesday , March 14, 2018 - 9:01 AM

Paige Winfield Cunningham

(c) 2018, The Washington Post.

As Rex Tillerson exits the State Department, he leaves behind a confusing trail of mixed messages about whether the Trump administration wants to support or undermine U.S. funding for global health.

President Donald Trump’s tweet yesterday morning that he’d fired Tillerson was sudden yet not surprising given the former oil executive’s fraught year as the country’s top diplomat. Tillerson’s tenure was marked by repeated clashes with the White House, a massive exit of talent from the agency he leads and an extreme reticence to interacting with the media.

Trump didn’t specifically cite Tillerson’s health-care policies as a reason for giving him the boot - the president instead pointed to disagreements in key areas of foreign policy such as the 2015 Iran nuclear deal and the approach to North Korea. But it’s easy to see why the two men were not on the same page when you look at how they approached major U.S. funding streams for priorities such as HIV/AIDS, maternal health and more.

Trump and Tillerson’s rhetoric did at times sounded quite positive toward funding major global-health initiatives. Trump used his first address to the United Nations to brag about U.S. investments in programs to take on AIDS, infectious diseases and human trafficking. And Tillerson occasionally expressed public support for global health programs, for example praising the Bush-era PEPFAR program in a major speech in October.

“PEPFAR has empowered people around the world to take their lives and their counties back,” Tillerson said at the time. “The Trump administration is committed to building on the progress we have already made by accelerating our approach that focuses on the hardest-hit populations.”

But the picture looks different when you consider Trump’s budget requests. The president called for sweeping cuts to virtually every funding stream in his 2018 budget plan last year and in the 2019 version the White House released last month.

The president’s most recent budget requested cuts of 18 percent for PEPFAR, which distributes medical supplies to combat HIV/AIDS in the developing world. The budget document seeks a 32 percent reduction for the Global Fund to Fight AIDS, Tuberculosis and Malaria; a cut of 24 percent for maternal and child health; and a whopping 50 percent slash for family planning and reproductive health.

“There was this rhetorical support, but the proposed cuts were so significant there seemed to be a disconnect,” said Jen Kates, director of global health and HIV policy at the Kaiser Family Foundation.

It’s unclear precisely why the administration has called for such deep cuts to global health aid. For one thing, it’s one area Republicans in Congress are typically eager to fund. Congress routinely allocated even more dollars for global aid than President Barack Obama requested during his two terms. A major hallmark of George W. Bush’s presidency was dramatically expanding AIDS funding through both PEPFAR and the global fund - now the two biggest funding streams for global health initiatives.

There’s another reason the proposed cuts were puzzling. Foreign assistance makes up less than 1 percent of the federal budget, and less than one-fourth of that goes to global health. So trying to trim these programs would do next to nothing to move the needle on U.S. spending, regardless of deficit concerns.

Tillerson didn’t publicly push back against the Trump budget, which would have been unusual for a Cabinet member, anyway. But he provided little evidence that he was making global health any kind of priority for the State Department. Instead, he’ll be best remembered for his effort to reorganize the agency, for which he received much criticism as key positions remained unfilled for months.

“I don’t know that global health was a particular focus for Secretary Tillerson at all,” Thomas Bollyky, senior fellow for global health at the Council on Foreign Relations, told me. “He tended to focus pretty heavily on institutional issues, a big departure from the past.”

There is one way global health programs appeared to be sheltered from the staffing upheaval in Foggy Bottom. Experts say Tillerson left in place or brought on top administrators with strong backgrounds in global health, including Deborah Birx, who oversees PEPFAR, and Mark Green, head of USAID.

But, as with many other areas of Trump’s administration, it’s often hard to figure out the direction or priorities for top Trump appointees. That is how many global health experts said they’ll remember Tillerson.

“Part of the problem is this administration has been inconstant in its support,” said Jeff Sturchio, president of Rabin Martin, a global health consulting firm. “You never know if it’s going to change its tune overnight.”


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