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As President Biden recommits to the WHO and the international community, Salzburg Global Fellow Andrea Feigl, Thomas Roades, and Erin Gregor - all of the Health Finance Institute - argue the incoming administration should invest more in the global fight for better health

While the new US administration is much-anticipated for many reasons, those of us in global health are eagerly waiting to see whether the new US will not merely rejoin the global community but ring in a new era of global health leadership.

In that vein, and as advocates for greater spending on the highest-burden diseases, we also have some ideas and hopes. What might the world expect from a renewed global outlook from the US administration? What should the world expect?

First, President Biden has already promised to "rejoin the WHO and restore [America's] leadership on the world stage." WHO's Director-General, Tedros Adhanom Ghebreyesus, congratulated President Biden and welcomed the opportunity to "reimagine leadership…to end the pandemic and address the fundamental inequalities that lie at the root of so many of the world's problems". Reestablishing US-WHO relations is a critical first step since the outgoing administration had frozen funding and began to "scale down its engagement with the WHO."

Second, joining the global effort towards an equitable vaccination strategy and eradicating COVID-19 at home and abroad will certainly be very high on the agenda.

However, one persistently neglected disease group – that of chronic diseases – ought to be a priority as part of any forward-looking global health strategy. COVID-19 --  all too painfully --- highlights that countries with the highest chronic disease burdens stand to suffer the most from infectious disease outbreaks, both in terms of health and economic impact. What's more, NCDs are the leading cause of death worldwide and account for over 70% of all global deaths each year. Efforts to combat these chronic diseases are chronically underfunded; just two percent of development assistance funding for health goes to NCDs. Therefore, as the incoming administration renews the US' commitment to the WHO and the global community at large, it should consider renewing and improving the country's commitment to fighting noncommunicable diseases (NCDs) as well.

The representation of chronic diseases on the US' global health agenda would be forward-looking and represent a clear break with past trends: historically, much more of the US' substantial contributions to global health were earmarked for communicable diseases, like HIV, tuberculosis, and malaria. In fact, in the Kaiser Family Foundation's detailed breakdown of the US government's funding for global health in 2020, NCDs don't even merit their own line item – presumably, they're buried within the one percent of funding classified as "other."

US Government funding for the WHO is similarly skewed towards communicable diseases and the additional priorities of polio eradication and combating hepatitis. Again, NCDs are relegated to just 0.5% of US funding to the WHO, a mere $3 million.  

The US is uniquely positioned to turn this tide and shift attention and funding in proportion to the disease burden. As the WHO's top funder, the creator of the ambitious PEPFAR plan, and a core contributor to the Global Fund, the US has traditionally spearheaded trends on the global health agenda. Focusing on and committing to NCD programming and funding would help the US re-emerge as a global health leader once more.

Still, given the past two decades' focus on infectious diseases – is there reason to believe that 2021 will be the year of a broadening global health agenda? Indeed, the officials who President Biden chose for his transition team bode well for a renewed effort in combating NCDs, especially in low- and middle-income countries.

Leading the transition team for international development were Linda Etim, formerly of the US Agency for International Development (USAID), and Elizabeth Littlefield, former head of what is now the US International Development Finance Corporation (USIDFC). Etim worked on development assistance funding to Africa during her tenure at USAID. As head of USIDFC (at the time known as OPIC), Littlefield worked to catalyze private investment from the US into LMICs to spur development. Before the Senate in 2013, she explained the importance of this work for "improv[ing] low-income families' access to energy, clean water, health services, and schooling." Both Etim's and Littlefield's track records suggest they will be well-suited to kickstarting efforts to re-engage the country in global health and development efforts.

The administration's most recent nomination in this field has been former UN Ambassador Samantha Power, who was nominated to be USAID Administrator on January 13. President Biden simultaneously announced that he would be elevating the position of USAID Administrator to a member of the National Security Council, in keeping with Power's experience in security work (including her time serving on the Council under President Obama). Power also has some experience working in global health, however, particularly during the Ebola epidemic – she convened the first-ever meeting of the UN Security Council focused on public health in response to that outbreak. We hope she will treat the slower moving but the far more deadly NCDs epidemic with similar urgency.

In 2021, President Biden also has the opportunity to appoint fresh talent to the WHO's Executive Board – another chance for the administration to signal its commitment to addressing NCDs. Under the Obama administration, Nils Daulaire filled the US seat on the Board. Daulaire has spoken to the urgent issue posed by NCDs several times, but as NCDs grow ever more deadly, rhetoric is no longer enough. The next administration's nominee to this position should be someone similarly aware of NCDs' urgent threat and someone who is ready to back those words with a financial commitment.

The new administration will require support from the legislative branch as well, as Congress has the power to set levels of funding for global health programs. The House and Senate Appropriations Committees, specifically, are closely involved in this process. The current Chairwoman of the House Appropriations, Rep. Rosa DeLauro (D-CT), has historically advocated for treating global health as a higher priority. And following the Georgia runoff elections, in which two Democratic wins flipped the balance of power in the Senate, Sen. Patrick Leahy (D-VT) is expected to take over as Chair of the Senate Appropriations Committee from current Chairman Sen. Richard Selby (R-AL). Sen. Leahy spoke out against the Trump administration's withdrawal from WHO and even introduced a bill to block the move – perhaps an encouraging signal for his attitudes on the importance of US leadership in global health.

Though increased funding to begin to close the NCD financing gap would be a great start, turning the tide on this issue will take more than just a cash infusion. Any action the incoming administration takes should be sustainable and high-impact – the burden of chronic diseases is large and will not disappear overnight. The US has an opportunity to lead, but real change will require real cooperation. If the administration aims to address this issue, they should be thinking about the levers of international governance and multilateral organizations that can generate concrete action, like the UN Multi-Partner Trust Fund Office, or expanding the mandate of the Global Financing Facility to include chronic conditions, for example.

Given the raging pandemic and the global interconnectedness of each nation's response, as well as the associated health and downstream economic effects, the incoming administration will place significant focus on global health. However, we hope and advocate that the focus on tackling the infectious pandemic does not come at the detriment of addressing what's killing and affecting most people: chronic diseases, such as mental health, diabetes, cancer, lung disease, and heart disease - the 'other' global pandemic that has been too out of sight for too long.

This article was written by Salzburg Global Fellow Andrea Feigl, Thomas Roades, and Erin Gregor - all of whom work for the Health Finance Institute. The article and comments represent the views of the authors and not necessarily those belonging to Salzburg Global Seminar.