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August 22, 2017

Garrett on Global Health

Dear friends and colleagues,

Though it is summer here in New York, a season usually marked by government recess and general lethargy, this July and August have witnessed a flurry of political and global health activity. But before reviewing them, I am excited to announce that I will, after more than thirteen years, be leaving the Council on Foreign Relations (CFR) to commence a new chapter, with new policy dimensions.

This newsletter will be the final edition of Garrett on Global Health published through CFR. Going forward, it will appear on my website, www.lauriegarrett.com, and I can be reached via laurieagarrett@gmail.com. Take note of the “a” between “laurie” and “garrett” in that email address (someone else has lauriegarrett@gmail).

U.S. Credibility Overseas and Implications for Global Health

With only one of the thirty-two high-level positions filled in the Department of State seven months into Donald J. Trump’s presidency, and thirty-nine top civil service positions vacated in something of an exodus, Secretary of State Rex Tillerson is unable to focus on matters of health and development. Only 30 of the 188 ambassador positions have been filled, primarily because the White House has not nominated candidates for Senate approval. Secretary Tillerson, the former CEO of the Exxon Mobil Corporation, is unhappy about the managerial flow charts and structure of the department that he inherited from the Barack Obama administration, and he has contracted with two firms—Deloitte and Insigniam—to execute “ReDesign2017” for both the State Department and the U.S. Agency for International Development (USAID). The private firms have carried out listening campaigns and surveys inside the State Department and USAID to garner the views and frustrations of government staff. The findings have not been made public, but much has leaked out, both via social media and in the Wall Street Journal and Independent. The thirty-five thousand respondents mostly complained about poor funding, antiquated technology and computer systems, bureaucratic entanglements, and the paucity of leadership amid the huge numbers of unfilled top positions.

Among the debates in the ReDesign2017 process is whether USAID ought to formally merge with the State Department, which would make the development agency adhere more closely to U.S. foreign policy interests. This is a long-standing debate; Democrats have been loathe to use health and development programs as leverage for larger foreign policy interests, and Republicans have been more in favor of alignment. Since Tillerson took the helm, opinion within the leadership has swung back and forth, and the debate seems to remain unresolved at this time. At one State Department staff meeting, employees were told that the State Department and USAID will “remain separate” but be “mutually dependent.” At a recent meeting for nongovernmental organizations (NGOs) that receive support from USAID, the agency’s leaders—as I was told by numerous individuals present at the gathering—said simply that, “Secretary Tillerson is in charge of both.”

Regardless, morale among diplomatic corps and civil service staff in both the State Department and USAID is low. There is anxiety that the agencies’ programs are being gutted. Deputy Secretary of State John Sullivan convened a town hall earlier this month to bolster spirits at the department, insisting that “the notion that’s been out in the press and in the media of a hollowed out State Department that is not effective, I think is counterfactual.”

In response to growing criticism over President Trump’s comments regarding white supremacists, Secretary of State Rex Tillerson delivered a remarkable speech in Washington on August 16, stating, “We do not honor nor do we promote or accept hate speech in any form and those who embrace it poison our public discourse and damage the very country that they proclaim to love.” He continued, “Racism is evil. It is antithetical to America’s values, it is antithetical to the American idea.” He also called attention to the small numbers of nonwhite upper-tier State Department employees and ambassadors. Without using the term “affirmative action,” Tillerson vowed to make the advancement of people of color within the State Department a top priority, noting, “Whether it is African American, Latino, Hispanic, women, LGBT [that] come with experiences I do not know, this enriches the quality of our work.”

Perhaps coincidentally, the State Department’s email system mysteriously collapsed after the secretary’s remarks about racism, due to some unstated system-wide failure. The worldwide outage has been credited to Russian hackers. It also followed President Trump’s announced decision to elevate the status of cybersecurity programs in the Department of Defense. Regardless of their primary motivation, the hackers demonstrated that the State Department’s communications system is no longer safe and secure.

The White House wants to cut the State Department and USAID budgets by a third. Next month, when Congress returns from summer break, the 2018 budget fight will commence, and everybody will learn just how deeply budget cuts will slice. Tillerson is reported to want layoffs of 2,300 State Department employees—much less than what the White House has proposed, but still roughly 5 percent. In July, the House Committee on Appropriations approved a $49.4 billion bill for 2018 foreign operations, cutting the budget by more than $10 billion from 2017. If the Senate follows suit and a final budget agreement is reached before the fiscal deadline (September 30), foreign aid programs that deal with health and development will be severely reduced. The appropriations committee vote ratified President Trump’s so-called gag rule, abolishing support for any overseas programs that provide information regarding access to abortion services, and preventing recipients of U.S. funding from collaborating—on anything—with nongovernmental groups that offer abortion education or services. This could imperil $8.8 billion worth of health and development programs in sixty-four nations. In addition, the Trump administration has cut $32.5 million in support for the UN Population Fund, which supports reproductive health and family planning services.

To offset the likely impact of the Trump administration “gag rule,” some forty nations committed to Family Planning 2020 during a summit in London in July. The Dutch government led the charge back in February, creating the $600 million She Decides fund. Also slated for likely excision is the State Department’s Bureau of Population, Refugees and Migration (PRM),which handles relocation of foreigners to the United States. According to the Center for Global Development, some parts of the State Department and USAID have already taken significant cuts, but global health spending in 2017 has mirrored that of 2016. It is anybody’s guess right now what the 2018 numbers will look like for the State Department, USAID, and dozens of other global health–related agencies and programs. The Kaiser Family Foundation predicts a 25 percent reduction in overall U.S. support for global health programs in 2018.

The foreign policy credibility of the U.S. government is, of course, about a great deal more than the budgets of its respective agencies and foreign aid. Until this year, the United States was the voice of globalization and the prime advocate of worldwide free trade. Possessing an armed forces budget far larger than all of the rest of the world’s militaries combined, the United States has the loudest voice and biggest stick in the world. Under the Obama administration that voice called for democracy, human rights, widening trade in Asia, an allied fight against terrorism, and calm opposition to nuclear proliferation in North Korea and Iran. Very rarely did the Obama administration publicly air divisions on foreign policies, and the State Department and White House gave outward appearances of unity.

Martin Wolf of the Financial Times, one of the world’s most highly respected economics journalists, described sharp contrast within the Trump administration. The president’s July oratory in Warsaw, Poland, on the eve of the Group of Twenty (G20) summit in Germany was, Wolf said, “a clash of civilizations speech,” depicting a West that is under siege from multiple forces, quaking in its boots. “And [Trump] knew, when he said this, this was a position that Western Europeans just don’t accept at all.” He continued, “What is the G20 for? The whole point of the G20 is that it’s a meeting of countries with very different cultures, very different political systems, who do recognize one thing—we share the planet. We have things we have to do in common to deal with global public goods like climate and the economy.”

And a couple of days later at the Hamburg summit, Trump broke from traditional protocol at a banquet by having a private discussion with Russia’s Vladimir Putin that lasted, by many reports, for nearly an hour. In a manner unthinkable for previous U.S. presidents, Trump used no talking points prepared by American experts, took no notes, brought no State Department or security personnel to his side, and allowed Putin’s aide to provide translation. All of this took place in front of G20 host German Chancellor Angela Merkel and eighteen other national leaders.

“The U.S. was alone at the G20,” Wolf wrote. “Despite papering over the cracks, the U.S. was alone on climate and protectionism. The transformation of the U.S. we are seeing might prove enduring. If so, the world has moved into a dangerous era.”

That astounding G20 display was perhaps the most jaw-dropping diplomatic Trumpism of the summer, but hardly the most significant. In Saudi Arabia, President Trump consented to the Saudi royal family’s war on Yemen, offering to sell the kingdom more fighter jets and providing support for Arab Sunni domination of the region. Days later, Saudi Arabia and the Gulf states leveled an unprecedented diplomatic assault on Qatar. They ordered the sovereign state to shutter the broadcast network Al Jazeera and clamp down on the activities of its citizens, imposed a trade sanction, and cast doubt on whether Islamic pilgrims from Qatar will be granted access to the 2017 hajj. With food running out and all manner of supplies threatened in Qatar, Tillerson flew to the region and brokered what would have been an agreement between the countries—but the White House refused to sign on, humiliating the secretary of state. Tillerson exploded, decrying meddling and chaos in the White House. Days later the secretary took time off, disappearing from public view.
 

Even before the G20 summit and Qatar flap, a Pew Research survey found global opinion of the United States had plummeted. In a survey of thirty-seven nations, the favorability rating was 64 percent at the end of the Obama administration, but merely 49 percent in late June. The Financial Times asked “whether Trump will inflict irreparable damage on the world order before he leaves office.” And Jamie Dimon, CEO of Wall Street giant JPMorgan Chase, decried the state of affairs in Washington, saying, “It’s almost embarrassing being an American citizen.”

In the few weeks since the G20 and Qatar incident, the Trump administration has threatened “fire and fury” against North Korea; opened renegotiation talks on the North American Free Trade Agreement (NAFTA), the trade agreement between the United States, Canada, and Mexico; and demanded that foreign governments and corporations open manufacturing sites inside the United States to fulfill his “America First” policy. This summer, Trump has also pulled the United States out of the Paris Climate Agreement, taken steps to reverse Obama’s opening of diplomatic relations with Cuba, vowed to impose further sanctions on Iran, and discussed privatizing the war in Afghanistan by turning military operations over to a private company controlled by a relative of his secretary of education. He threatened military action to bring down President Nicolas Maduro of Venezuela, demanded that Chinese President Xi Jinping cease violations of U.S. patents and intellectual property, and thanked Putin for helping create a “smaller payroll” after the Russian leader ordered the expulsion of 755 U.S. diplomatic personnel from the country. He toadied to Turkey’s Recep Tayyip Erdogan and said nothing when the visiting leader unleashed his personal shock troops on Kurdish protestors in front of the White House, in full view of the U.S. Secret Service and Washington police officers.

Embroiled in multiple legal investigations of Russian cyber interference in the 2016 elections and possible collusion with Moscow, the White House witnessed revelations nearly every day this summer that further undermined claims of “no contact” with Russian leaders, spies, or financial interests. Stephen Sestanovich, of Columbia University and the Council on Foreign Relations, argues there is no coherent Trump foreign policy or doctrine, merely opposition to the “liberal international order.” Another CFR colleague, Max Boot, lists President Trump’s many foreign policy actions and statements alongside the complete failures of all of his legislative domestic initiatives as evidence that “Trump is shrinking before our eyes, and that’s saying something since he was already a moral and intellectual pygmy when he took the oath of office. He’s on the fast track . . . to WPE: Worst presidency ever.”

And all of that preceded the horror of white supremacists marching in Nazi and Ku Klux Klan regalia in Charlottesville, Virginia, where an automobile was used as a weapon against anti-Nazi protestors, killing one woman and hospitalizing nineteen others. A day after the events in Charlottesville, German Chancellor Angela Merkel said, “It is racist, far-right violence and clear, forceful action must be taken against it, regardless of where in the world it happens.” The United Kingdom’s Prime Minister Theresa May said through a spokesman, “We are very clear. . . . We condemn racism, hatred, and violence. We condemn the far right.” Israeli President Reuven Rivlin wrote, “The very idea that in our time we would see a Nazi flag—perhaps the most vicious symbol of anti-Semitism—paraded in the streets of the world’s greatest democracy and Israel’s most cherished and greatest ally, is almost beyond belief.” Similar statements of outrage poured in from heads of state all over the world.

The foreigners seemed to understand American history and racism better than the president of the United States, who insisted that a so-called alt-left was in the streets, violently attacking “some very fine people” who went to Charlottesville to protest the removal of a statue of Robert E. Lee, the man who led the military of the1860s secessionists, united in a Confederacy to defend slavery in the United States.

There are many tragedies to cite as summer wanes in the United States. For those who have dedicated their professional lives to improving the health, prosperity, and security of humanity, the loss of the United States’ role as a shining beacon of hope, human rights, and foreign assistance is unnerving. There is a sense that in just seven months’ time the ground has been pulled from under their feet, displacing the dreams of a globalized community striving, together, for the betterment of all. Perhaps nothing captures this sense of looming dystopia and loss of collective aspirations as vividly as White House aide Stephen Miller’s August 2 dressing-down of CNN correspondent Jim Acosta over the words inscribed beneath the feet of the Statue of Liberty. Referring to President Trump’s decision to exclude immigrants that are not English-speakers of economic value to America, Acosta asked Miller, “What the president is proposing here does not sound like it’s in keeping with American tradition when it comes to immigration. The Statue of Liberty says, ‘Give me your tired, your poor, your huddled masses yearning to breathe free.’”

“It’s a symbol of American liberty lighting the world,” Miller rebutted. “The poem that you’re referring to, that was added later, is not actually a part of the original Statue of Liberty.” Miller was echoing the position of the Ku Klux Klan, which insists the poem, authored in 1883 by New York–born poet Emma Lazarus, was the work of a “Jewish communist.” Born into a wealthy family, Lazarus was sympathetic to the plight of Jews fleeing Russian pogroms, long before the existence of communism or the Soviet Union.

Recent Work

Climate Change

Former U.S. Vice President Al Gore has a new book and movie out, both titled, An Inconvenient Sequel: Truth to Power. I was asked to review the works for the Lancet. The review opened, “As the Donald Trump administration punches holes in American democracy along its seemingly inevitable path to Nixonian demise, the man who should have taken the oath of Presidential office in 2001 stands in such stark contrast to the current residents of 1600 Pennsylvania Avenue as to seem from another age, place, and even country.”

I thought Gore’s efforts ought to be compared to another new book on climate change, Climate of Hope by former New York City Mayor Michael Bloomberg and former Sierra Club President Carl Pope. Both books offer hopeful perspectives, imagining that grassroots activism and renewable energy (Gore) or the leaders of cities and big business (Bloomberg and Pope) will eventually overcome the economic and political pressure of the fossil fuel industry to save the planet from a dire, cataclysmic future.

In his movie, Gore offers evidence that the 2016 Zika virus pandemic was a climate-induced event, and describes other possible effects on human health from rising temperatures and extreme weather. His book, however, glosses over human health issues. Bloomberg and Pope provide far more detailed and nuanced discussion of the public health and clinical effects of climate change, and Bloomberg writes that it was public health that brought him to the climate table.

Overall, I believe both books are overly optimistic. There is a strong belief in climate change circles that political inaction on carbon dioxide (CO2) is the result of an overly grim, even despairing message. Gore says there has to be hope for social action to ensue. Fair enough, but two papers published this summer challenge my ability to believe that the world can be saved with increased sales of solar panels and wind turbines. First, a team of prominent scientists including James Hansen, the NASA scientist who first sounded alarms about climate change in the early 1980s, published “Young People’s Burden: Requirement of Negative CO2 Emissions.” The paper argues that the Paris Climate Agreement’s target of holding average temperature increase over preindustrial norms to +1.5 degrees Celsius was nearly eclipsed in 2016 when temperatures topped +1.3 degrees Celsius. Worse, the scientists say the planet is already well beyond sea level and temperature ranges previously seen in the Holocene geological era, and is swiftly approaching the prior Eemian period when sea levels averaged six to nine meters (twenty to thirty feet) higher than today. The authors insist that nothing short of a planet-wide geoengineering effort to capture carbon from the seas and atmosphere, costing hundreds-of-trillions-dollars, can prevent the world from devolving into an unlivable state before the end of this century.

Striking a similarly grim, urgent note, a team of American and British scientists wrote a study, “Importance of the Pre-industrial Baseline for Likelihood of Exceeding Paris Goals,” that argues less than five years at current CO2 emissions rates remain before the planetary temperature tops a genuine preindustrial baseline, topping +1.5 degrees Celsius.

HIV/AIDS

During the International AIDS Conference in July, I published “The Next AIDS Pandemic.” I wrote that a second global pandemic of AIDS is likely, barring a phenomenal increase in worldwide financial and political commitment, for three reasons: Only half the world’s HIV-positive population is currently receiving treatment that can lower their viral loads sufficiently to make them noncontagious to their sexual and drug use partners; there is not enough drug production capacity to manufacture affordable medicines for the current HIV-positive population, and that population is currently growing; and some 10 percent of new infections in 2016 involved already drug-resistant strains of HIV, forcing the use of more costly and difficult to make medicines.

CHOLERA

At the end of July, I wrote “Cholera Is Slaughtering Yemen and We’re Letting It Happen” in Fortune. I argued that the cholera catastrophe in the Horn of Africa and Middle East is man-made, far larger in size than regional governments admit, and likely to top half a million cases in Yemen alone by August. Indeed, the World Health Organization (WHO) recently declared that the toll in Yemen has surpassed five hundred thousand cases, with at least two thousand deaths.

VACCINES

When the Court of Justice of the European Union (CJEU)—the EU’s highest judicial body—handed down a decision on suing vaccine manufacturers, I wrote “Science Won’t Save Vaccines From Lawsuits Anymore.”

The article was published five days after the decision on June 21, and since then a maelstrom of reactions and legal interpretations has emerged, both in Europe and the United States. A careful analysis by Nature reporters Laura Castells and Declan Butler concludes that the ECJ did not rule against the value of science in vaccine liability cases, but insisted a burden of proof rests on the plaintiff. The writers warned, “The most worrisome outcome of the ruling might be that it increases public suspicion of vaccines, which is already substantial in France.” In contrast, Oxford University pediatrics professor Andrew Pollard said that the ECJ ruling “does not appear to be consistent with the normal rational scientific approach to analysis of evidence.” In the United States, prominent pediatric immunization expert Paul Offit of the University of Pennsylvania opined that, based on the ECJ criteria, “you could reasonably make the case that someone should be compensated for developing leukemia after eating a peanut butter sandwich.” And science blogger Orac summarized his take-home message as, “Quoth the Court of Justice of the European Union: ‘Let’s make it easier for plaintiffs suing for “vaccine injury” on dubious grounds to prevail!’”

There is also plenty of confusion and disagreement among legal scholars. Harvard Law professor Alex Stein argued that scientists have overreacted to the ECJ ruling because they do not understand that it is a minor tweak in a larger EU body of law that weighs the risk to the individual against a vaccine’s proven utility in saving millions of lives. University of California, Hastings, law professor Dorit Rubinstein Reiss says the important thing to note about the ECJ ruling is that “if there is no scientific consensus as to whether a vaccine causes a particular kind of injury, member state courts can allow plaintiffs to use circumstantial evidence.” However, Reiss warns, in what seems classic understatement given all the confusion, “This is a complex decision.”

Finally the anonymous Skeptical Raptor, a former pharmaceutical industry “schiller,” as the blogger puts it, referees a popular website dedicated to “stalking pseudoscience in the internet jungle.” In a lengthy back-and-forth analysis of the EU court decision, the Skeptical Raptor plays one legal scholar against another, finally offering a conclusion about which there can be no debate: “If courts had control of science, and they suddenly decided that correlation can equal causation, then we need to rewrite a bunch of books in epidemiology and statistics.”

THE FUTURE

In early 2017, the BBC asked many experts to opine about dangers in the future. I was asked to speculate about the future of CRISPR and synthetic biology. I only recently stumbled on the result—“50 Grand Challenges for the 21st Century”—and, looking at my comments months later, I see the risks of forecasting. The field has already well surpassed the innovative biology I was “predicting.”

In another futurist collective effort, I was honored to participate in the special seventieth anniversary issue of the Journal of International Affairs. In the company of far wiser writers with deeper governance experience than mine, I wrote the essay “Global Health in a Populist and Nationalist Age.” The piece looked at the links between global health and globalization, questioning whether the programs built over the last thirty years can survive the post-Brexit, post–Trump election era. The essay was written around the New Year: you can decide if it stands up today, eight months later.

OBAMA

When I wrote the Journal of International Affairs essay I was, like many around the world, reeling from Trump’s victory and inauguration. It seems remarkable that a year ago today Barack Obama was president of the United States. The White House and cabinet members looked like America: multiracial, just about equally male and female, some openly gay, some physically disabled. It is almost impossible to contemplate what the norm in Washington was a year ago, given how wildly the capital has shifted since January.

Mark Greenberg pulled together Obama: The Historic Presidency of Barack Obama - 2,920 Days, and I was honored to contribute the essay on Obama’s global health legacy.

OPIOIDS STATE OF EMERGENCY

President Trump recently declared a state of public health emergency regarding America’s opioids addiction catastrophe. In his remarks on the topic the president indicated two concerns: first, that efforts focus on preventing opioid use in the first place, and second, that entry of drugs from Mexico be blocked. In Foreign Policy I wrote, “How Not to Handle the Opioid Crisis: America’s Drug Pushers Aren’t in Mexico—They’re Right at Home.” I laid out three policy prescriptions aimed at Trump’s intention to prevent addictive use of the drugs. First, target the lawful pharmaceutical manufacturers that evidence shows knowingly make and promote use of their drugs in quantities far in excess of medicinal application and go after retailers that fill prescriptions to individuals and entire communities at clearly excessive levels. Second, block all attempts by American companies to export non-medicinal uses of the drugs to other countries, thereby expanding the addiction crisis beyond our borders. And third, fully stop the importation of fake and derivative opioids from overseas, especially from China and India.

MOVING ON, FROM THE COUNCIL ON FOREIGN RELATIONS TO . . .

When I started at the Council on March 8, 2004—deliberately, on International Women’s Day—a visiting fellow had already laid some ground work and garnered funding from the Bill & Melinda Gates Foundation for a nascent global health program. His name was Jordan Kassalow, an optometrist who went on to build one of the most fantastic NGOs in the global health space: VisionSpring. Thanks to Jordan and his team, today more than 3,700,000 people in developing countries can read and work because they have corrective lenses. I witnessed VisionSpring in action, purely coincidentally, when I was in Bangladesh. A woman entered the village I was in, clutching her official VisionSpring briefcase and shouting in Bengali, “Who here is having trouble reading? Who can’t see to work anymore?” Middle-aged men and women poured out, an eye chart was erected, and in a few minutes the first client was wearing a pair of glasses and holding a newspaper. She peered at the paper and burst into tears, exclaiming, “I can read! I can see the news!” A few days later at a rug factory, I saw dozens of men and women doing needle work, all wearing VisionSpring glasses. As Jordan explains, a pair of glasses increases productivity by 35 percent, and monthly income by up to 20 percent.

Jordan left a legacy for me that was tough to follow. Over the years at CFR I have chaired countless meetings, given innumerable speeches, and written god-knows-how-many studies, papers, op-eds, blogs. And I have been blessed with a terrific list of research associates (RAs), interns, and colleagues. Each team has been wonderful. It has been an honor to work with bright, young RAs and to see them go on to marry, have families, and contribute professionally to the world. In the strongest possible terms I want to thank them all:

  • Scott Rosenstein was my first RA at CFR. Today Scott is part of the 100 Resilient Cities program at the Rockefeller Foundation in New York.
  • Kammerle Schneider followed Scott, and today is deputy director of the malaria control and elimination partnership in Africa at PATH in Seattle.
  • El-Haum Alavian was my third RA. Today she teaches public health at the University of Lusaka in Zambia.
  • Zoe Liberman followed. She is now part of the staff of the department of population health at New York University’s medical center. 
  • Daniel Barker and Zoe overlapped at CFR. He is now a strategy senior consultant at Deloitte in New York.
  • Kathryn Salucka was both an intern and RA. She now works for the African Studies Association in Piscataway, New Jersey.
  • Maxine Builder also worked with me as both an intern and RA. Journalism was her calling, and she now writes for the online magazines Bustle and Extra Crispy.
  • Gabriella Meltzer just departed this May to start her doctoral studies in global environmental health at New York University.
  • And finally, Alex Ameter has pitched in as a temporary RA this summer. He will remain at the Council on Foreign Relations, providing RA services to the 2017–2018 crop of visiting military fellows.
 

With their help, during my years at the Council I have managed to have some small impact on global health, U.S. foreign policy, and the larger range of what Joseph Nye dubbed “soft power” issues.

HIV/AIDS

I began by working with analysts from all over the world—especially sub-Saharan Africa—to establish the links between HIV/AIDS and national security. In 2005, I published the CFR report HIV and National Security: Where Are the Links? Nearly ten thousand copies were distributed through the UNAIDS Program, the UN peacekeeping operation, and the U.S. armed forces.

BIRD FLU

Also in 2005, the H5N1 bird flu underwent a significant mutation in China, allowing the virus to infect a substantially broader range of avian species that carried the dangerous microbe across Siberia to Europe, the Middle East, and West Africa. Though the numbers of human cases from China to West Africa were small, the virus’s virulence was acute, and about 60 percent of those infected died from the disease. Writing in Foreign Affairs, I drew attention to the dangers inherent not only in the then-circulating H5N1 strain, but for pandemic influenza writ large. I briefed staff of the National Security Council, State Department, and Congress, and provided input for the George W. Bush administration’s pandemic preparedness plan. At Undersecretary of State Paula Dobriansky’s request, I briefed top State Department officials on the virus, its links to live animal markets, and the difficulty of controlling it.

The International Health Regulations (IHR) went into effect in 2005, and avian flu presented an immediate challenge to their implementation. The Indonesian government declared that a novel notion—“viral sovereignty”—existed, allowing a nation to refuse sharing samples of H5N1 strains found on its soil with any outsiders, including the WHO and U.S. Centers for Disease Control and Prevention (CDC). With international legal expert David Fidler, of Indiana University, I wrote an analysis of international obligations in outbreaks and potential pandemics, and delivered a 2007 TED Talk on influenza. Together with Ambassador Richard Holbrooke, I directly challenged the Indonesian notion of viral sovereignty, denouncing its failure to share viral samples as “morally reprehensible.”

DURC, GOF, AND SYNTHETIC BIOLOGY

Over the years, I convened multiple meetings and penned several papers on influenza, especially related to so-called dual use research of concern (DURC) and gain-of-function research (GOF), both of which are laboratory science pursuits that aim to decipher the genes and proteins responsible for turning an avian or swine virus into a human-to-human transmissible agent. The earlier DURC innovations used ferrets as substitutes for humans, submitting the virus to brute force mutation by simply passing flu over and over through the mammals until it seemed to adapt to ferret lung receptors. The concern was that DURC could be used for nefarious purposes, creating what would amount to a cataclysmic bioweapon. With GOF, scientists use more refined genetic methods to specifically give an animal influenza the capability of infecting and spreading among mammals.

The DURC and GOF scenarios took great leaps forward with the advancement of synthetic biology and, most recently, CRISPR alteration of genomes. I produced a CFR video to explain the status of these issues in 2013, and a Policy Innovation Memorandum suggesting steps the U.S. government might take to minimize the bioweapons and simple biosafety risks inherent in DURC, GOF, and synthetic biology. I participated in and hosted multiple meetings at CFR on the topic, and wrote a cover story for Foreign Affairs, “Biology’s Brave New World.” I briefed high-level officials on these issues in Tokyo, Beijing, Singapore, the UK, and, of course, Washington.

9/11 AND ANTHRAX

Over much of this time, I researched and wrote I Heard the Sirens Scream: How Americans Responded to the 9/11 and Anthrax Attacks, which was published on the tenth anniversary of the September 11, 2001, al-Qaeda attacks and subsequent anthrax mailings. The book focused on the day-by-day reactions and slow recovery of New Yorkers in particular, demonstrating that the combined impact of the terrorist events was far greater than the simple sum of the two, and that anthrax panic resonated worldwide with an economic toll nobody could have imagined.

IMPLEMENTATION OF INNOVATIONS

At the urging of a unique group of CFR Term Members, I organized a series of meetings that looked at proven technologies for health, asking why implementation proved so difficult. Jordan Kassalow’s provision of reading glasses to far-sighted individuals in developing countries was a perfect example: Americans can get reading glasses so cheaply that middle-aged adults think little of losing a pair. But for the bottom billion people on the planet, the slow deterioration of eyesight with age is uncorrectable and renders them eventually unable to work, read, or even vote.

VACCINES

Perhaps the most frustrating example of underused health technology is vaccines, and for years I have tracked outbreaks of immunization-preventable diseases, such as measles, mumps, pertussis, polio, and diphtheria. In 2008, I launched the interactive Map of Vaccine-Preventable Outbreaks, which has had more unique visits than any other feature on CFR.org. Since its launch, my team—RAs and interns—has updated the information weekly, so that today the map is a powerful tool for recognizing trends worldwide.

With my departure from CFR, the map is moving. I take tremendous pride in announcing that the vaccine map will soon appear on the website of the Global Vaccine Alliance (GAVI), where the staff will build upon our years of work to routinely update the map and hopefully also expanding upon its current features. The map will continue to appear on CFR’s website, remain open-source, and retain its embed features that allow organizations and companies all over the world to position it on their websites, as well.

DOC-IN-A-BOX

One of my first innovation projects involved what I called Doc-in-a-Box: converted shipping containers that would function as frontline health clinics operated by minimally trained community health workers who would own their box and operating under franchise agreements. The boxes would be monitored and supervised via cell phone links to central hubs, staffed by registered nurses and physicians. The architecture department at Rensselaer Polytechnic Institute made a prototype, which was hauled into New York City and displayed in front of CFR’s Park Avenue headquarters. Over the years, many organizations have implemented some elements of the Doc-in-a-Box concept in Haiti, Kenya, and Sierra Leone. A Kansas-based group, Primary Mobile Med International, now has a contract to provide more than three thousand converted boxes to create a health-care network for Ghana. Stay tuned.

GLOBAL HEALTH GOVERNANCE

Ten years ago, Ambassador Princeton Lyman, then a senior fellow at CFR, asked me to assess the status of global health programs at a time when funding had reached record-breaking levels. My analysis appeared in Lyman and Patricia Dorff’s CFR book, Beyond Humanitarianism: What You Need to Know About Africa and Why It Matters. I argued that the rush to fund disease-specific programs was pitting global programs against one another, fragmenting leadership into a series of silos and draining the meager supplies of medically skilled personnel from frontline treatment and public health programs in poor countries. I warned that fragmentation of the architecture of global health had the entire enterprise moving ahead, without vision or even serious targets for long-term achievement.

This fragmented health situation, as I described in Foreign Affairs, witnessed on-the-ground conflicts, and even backstabbing, among UN agencies and multilaterals. Not long after Ban Ki-moon took the reins as UN secretary-general, he asked if I might bring the relevant parties together to hammer out these differences and agree on a shared vision for the future of global health. Together with former Irish President Mary Robinson, I organized an extremely intense, closed-door meeting at UN headquarters involving the heads of every major health-related agency, from WHO and UNICEF to the Global Fund and World Bank. I also made sure a few tough public health grassroots leaders were in the room, to speak truth to power. The presence of former U.S. President Jimmy Carter seemed to bring a special air to the gathering, with all participants taking their charges seriously. By the end, Secretary-General Ban was prepared to commit to health as one of his top three priorities, and the health leaders agreed to harmonize their efforts.

The mood in global health seemed buoyant, even giddy, by 2008, especially after Obama was elected U.S. president.

FOOD, FAMINE, AND AID

But also in 2008, the world’s financial and food crises began. In a working paper for CFR’s Center for Geoeconomic Studies, I described the how and why food prices soared in 2008, starting with Asian rice, national hoarding of stockpiles, and speculation investment strategies. I laid out strategies wealthy nations, especially the United States, ought to follow to reorganize their famine relief and food aid programs in order to bring prices back to sane levels. 

The arrival of a new U.S. president and dramatic shift in the political balance in Washington offered hope of fundamental reform of U.S. foreign assistance and humanitarian aid programs, moving more resources to places in need and reducing needless overhead and bureaucracy here in the United States. Backed by a strong team of advisors, I prepared a CFR report, released in Washington the week after Obama’s inauguration, “The Future of Foreign Assistance Amid Global Economic and Financial Crisis.” It detailed the nature of the necessary restructuring and reforms to the entire U.S. foreign assistance effort, noting, “America needs a new face in the world, and in return the world needs calm, stability, and hope for long, healthy, productive lives. Strategically inspired, well-coordinated foreign assistance efforts can bring America a new seat at the international table.”

In 2010, I saw the Russian wheat crisis unfold, following unusually hot weather and massive crop fires. The price of wheat, bread, and eventually every food commodity rose steadily that year and reached historic levels in 2011. I warned that wheat-dependent Egypt and the Middle East were especially hard hit, and food riots could spawn instability in the region. Indeed, food trader Mohamed Bouazizi had already protested rising prices in Tunisia by setting himself on fire, and the Arab Spring soon commenced.

UNAIDS

In early 2009, Peter Piot stepped down from leadership of the UNAIDS Program, and Mali’s Michel Sidibe took the helm. At his request, I organized two intense days of meetings, with participants drawn from around the world, aimed at defining the future role of the HIV/AIDS agency. As the year unfolded, I, like just about everybody working in global health, was overwhelmed by the H1N1 swine flu pandemic—an outbreak that showed the frailties of epidemic response capacity, the problems with hoarding vaccines and medical supplies, and the extraordinary speed with which influenza can spread globally. Fortunately, H1N1 was, as I put it, a wimpy virus—very contagious, but not particularly virulent.

CONTAGION

At that time, I was working with the screenwriter Scott Z. Burns, former smallpox-chaser Larry Brilliant, and Columbia University virus hunter W. Ian Lipkin to develop a pandemic film for Participant Media. The unfolding H1N1 pandemic eerily mirrored our original script ideas, forcing us back to the drawing board. The result was Contagion, directed by Steven Soderbergh, with an all-star cast including Matt Damon, Kate Winslet, and Jude Law. The film opened in 2011 and continues to resonate today.



FRAUDULENT PHARMACEUTICALS

Margaret Hamburg was named commissioner of the Food and Drug Administration (FDA), where she came to appreciate how dependent the United States had become on foreign-made active pharmaceutical ingredients as the basic ingredients of the drug industry. It seemed to be a Wild West situation, almost devoid of global governance, filled with fraud, counterfeiting, medicines contamination, and homicidal outcomes. Hamburg, a long-standing member of CFR, asked that we look at the policy options for minimizing worldwide pharmaceutical fraud. Her policy staff at the FDA was smart and dedicated, and we worked very well together. In 2012, I released a Policy Innovation Memorandum, “Ensuring the Safety and Integrity of the World’s Drug, Vaccine, and Medicines Supply.” I was honored when Roger Bate of the American Enterprise Institute, commenting on a 2012 resolution by the Group of Eight (G8), kindly wrote, “Laurie Garrett deserves much credit for this statement,” citing my memorandum.

EBOLA

The day after Christmas 2013, a toddler in the remote Guinean village of Meliandou fell ill, and by late February 2014 a chain of transmission unfolded in Guinea and neighboring Sierra Leone and Liberia. Confirmed as Ebola in the third week of March, the virus continued to spread, even as WHO and other international responders declared the problem to be under control and pulled out of the countries. Having been in the 1995 Kikwit Ebola outbreak, and having noted its far-flung spread in villages connected by little more than foot paths, I grew increasingly angry about the lackadaisical global response. Hachette released an ebook of my writing about Ebola, and I continued to beat the drum for a serious escalation in WHO and other parties’ efforts.

WHO finally declared a global emergency, activating the International Health Regulations in mid-August, but little aid and assistance reached the overwhelmed nations until October. “World,” I wrote on September 6, “you still just don’t get it.”

General Martin E. Dempsey, chair of the Joint Chiefs of Staff, asked me to address the chiefs at the Pentagon after Labor Day. With tremendous help from CFR’s visiting military fellows, I mapped out a seven-page strategy for U.S. armed forces engagement in Liberia, presented it, and to my amazement saw General Dempsey stand up, clutching a copy in his hand, and announce, “I’m going to the Oval Office.”

In October and November, I saw firsthand the tragedy of the international nonresponse, foot-dragging, and disorganization in Sierra Leone and Liberia. I also witnessed bravery and brilliance from local scientists, government employees, and healthcare providers. With tremendous support from the editorial staff of Foreign Affairs, I published a lengthy analysis of the epidemic and response. And I was a member of an independent panel, organized by Harvard University and the London School of Hygiene and Tropical Medicine, that scrutinized the global response. After months of sometimes painful debate and rewriting, the panel members agreed on where the blame lay and published recommended policy changes that were necessary to render the world better prepared for the next epidemic. This year, the panel reconvened to assess policy change, concluding there had been “ample analysis, inadequate action.”

ANOTHER MOVIE

During my work on the epidemic, I was followed at times by a documentary film crew. The movie was released this year, titled Unseen Enemy. Produced by former ABC News executive Janet Tobias, the film has aired all over the world—on CNN in the United States—and will be rereleased soon in commemoration of the hundredth anniversary of the great influenza pandemic, also known as the Spanish flu.

BACK TO GOVERNANCE

Over the years, I have learned that governance is the most critical factor in epidemic responses. Sure, having vaccines and protective suits for doctors is important, but none of that gets where it is needed, when it is needed, if systems of governance are not in place. Over the years I have become increasingly exasperated by WHO, while at the same time realizing how desperately the world needs that organization. In a recent Expert Brief, I lay out why the eradication of polio could, counterintuitively, spell doom for WHO.

I have learned a tremendous amount here at the Council on Foreign Relations about governance, especially from my colleagues Yanzhong Huang and Stewart Patrick. And from CFR President Richard N. Haass, I gained further understanding, particularly from his 2009 book, War of Necessity, War of Choice—a modern classic about the two U.S.-Iraq wars.

ONWARD

For several years I have been a featured “Voice” in Foreign Policy—a position I will happily retain as long as they will have me.

But it is now time for a new chapter. In the age of Trump, I find it increasingly difficult to speak in a measured, nonpartisan tone. Moreover, I have discovered a new stage of global crisis that demands special urgency and attention. Stay tuned.

In the meanwhile, as of September 1, 2017, send your correspondence to laurieagarrett@gmail.com and take a look in coming weeks at the soon-to-be-launched new version of www.lauriegarrett.com. After more than thirteen years, it is time to move on.

Of course I cannot reference my paltry thirteen years at CFR without tipping the hat to my great mentors, beginning with David Perlman, who just resigned from the San Francisco Chronicle after serving as the newspaper’s science correspondent for an astounding seventy-seven years. Yes, until last month, David Perlman, age ninety-eight, was still a working daily journalist. Finally, in July, he put down his reporter’s notebook, declaring, “It’s high time. My God, I’m 98 years old. If I’m not gonna quit now, when am I gonna quit?"

And Leon Wofsy, who was my mentor in the department of bacteriology and immunology at University of California, Berkeley, during my PhD studies, is still hard at work on his blog and political troublemaking at the age of ninety-nine.

Les Payne is a comparative spring chicken at the age of seventy-six, but I continue to learn so much from him that I hardly know where to begin. Les was my uber-editor at Newsday, a Pulitzer Prize winner who guided me to my own Pulitzer-worthy work. Born in Tuscaloosa, Alabama, Les was an African American child in the Jim Crow south, a soldier in the Vietnam War, and a stickler for journalistic accuracy and detail. Not long after returning from Vietnam—where he was General William Westmoreland’s speechwriter—Les went to work at the then nearly all-white Newsday and joined a team of four reporters on “The Heroin Trail,” tracking the story from a teenaged overdose in the New York City suburbs all the way to a poppy field in Afghanistan. Yes, that is what got him that Pulitzer Prize.

On to the next chapter. Details to follow. Happy Trails. And so it goes.


Laurie Garrett

Laurie Garrett
Senior Fellow for Global Health
Council on Foreign Relations

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