U.S. Health and Its Global Implications

In a special event copresented by the Council on Foreign Relations and The Lancet, panelists discuss priorities for improving public health in the United States and abroad.

BOLLYKY: Good morning. Welcome to the Council on Foreign Relations. My name is Tom Bollyky and I’m the director of the Global Health Program. It’s my great pleasure and honor to be collaborating with The Lancet on this event on U.S. Health and Its Global Implications. Richard Haass, my former boss, famously wrote a book about how U.S. foreign policy begins at home. And the same is true with U.S. Global Health engagement. The biggest threats now to America’s health security and welfare now come from—not from outside its borders, but from within. The way in which the U.S. pursues health abroad is profoundly affected by U.S. health at home.

And what do we know about U.S. health? The U.S. has the shortest average life expectancy among its high-income country peers. The Lancet special issue on U.S. health, released last week, highlights the growing geographical, racial, ethnic, gender, and socioeconomic disparities in U.S. health. Risk factors, including obesity, tobacco use, poor nutrition, are fueling deaths from noncommunicable diseases such as cancer, diabetes, and cardiovascular disease. And limited access to health care and financial protection from health-care costs is worsening outcomes from those conditions.

And it’s the same problems that the U.S. fails to take seriously at home are the same problems that it fails to take—address abroad, including noncommunicable diseases, universal health coverage, and risk factors like tobacco use and excessive alcohol consumption. Diminished confidence in U.S. government agencies and in multilateral institutions threatens to upend the work that agencies and institutions do to prevent and respond to health emergencies at home and abroad. For the U.S. to continue to engage successfully on health abroad, it must also successfully re engage on the U.S. health crisis at home, now and for the foreseeable future. And it’s critical that we engage the incoming administration on this agenda and look for opportunities for progress where they exist. And this special issue offers ideas for doing so.

With that said, we have an all-star event for you today. So I’ll take a moment just to explain the run of show. After me you will hear from The Lancet’s esteemed Editor-in-Chief Richard Horton, who is always thoughtful and provocative, and I look forward to that today; followed by a panel representing the different facets of the opportunities and risks for U.S. health at home and abroad: Rebecca Bunnell, the principal deputy secretary of the U.S. Global AIDS Response; Victor Dzau, the president of the U.S. National Academy of Medicine; Mona Hanna, the professor and leading researcher of the Flint water crisis; and Christopher Murray, director of the Institute for Health Metrics and Evaluation and lead author on many of the research papers in this issue. The panel will be moderated by my good friend and colleague, John Monahan from Georgetown. So thanks to him for doing that. And we’ll have closing remarks from Miriam Sabin, the editor of The Lancet’s special issue on U.S. health.

Just a quick moment of thanks for the many people that made this event possible. Thanks, of course, to my boss, Mike Froman, for the support for this event. Also to Stacey LaFollette, Carrie Bueche, Sam Dunderdale, and Chloe Searchinger from the Council on Foreign Relations, Miriam Sabin and Johanna Harvey from The Lancet. And thanks to Bloomberg Philanthropies for their financial support. And with that, let me turn it to Richard for his opening remarks. (Applause.)

HORTON: Well, thanks very much indeed, Tom, for that warm welcome. And let me just thank you and the Council on Foreign Relations for hosting us today. I’d also like to begin by thanking my excellent team, Miriam Sabin, who really put together this whole project so brilliantly. And also, I’d like to thank Johanna Harvey and Matt Gilbert as well for their brilliant support. Nothing ever happens without partnerships. I’d like to thank Ali Mokdad and the team at the Institute for Health Metrics and Evaluation. And, of course, Victor Dzau and the partnership with the National Academy of Medicine.

Now I regret having to, but I don’t apologize for, beginning in slightly somber mood. The assassination of Brian Thompson, chief executive officer of United Healthcare on the streets—on the streets of New York City on the 4^th of December, while he was on his way to an investors meeting, has catapulted American health care, its inconsistencies, its injustices, once again into the political spotlight. With the words deny, depose, and defend written on three bullet casings, attention has understandably focused on the practices of the American insurance companies, with allegations around delaying payments of justified claims, denying payments altogether, and defending actions by forcing patients into litigation.

Now you will see that, as Tom has mentioned, this theme issue is indeed focused on the health of Americans—the burdens of disease, injuries, and risk factors, the disparities in life expectancies, the disparities by race and ethnicity, age, sex, and location, the prevalence of overweight and obesity, and forecasts out to 2050 of the burden of disease. A few weeks ago, we launched another project, a commission led by a former U.S. Treasury Secretary Larry Summers. It was entitled Global Health 2050. And Larry Summers drew an optimistic conclusion about the future, that we could indeed, as a world community, halve preventable mortality by 2050, a fifty by ’50 goal.

But Larry was less optimistic about the situation facing the United States. The estimated probability of premature death in the U.S. is around 22 percent, behind South Korea at 12 percent, Japan at 12 percent, the United Kingdom at 16 percent, and even China at 21 percent. And to halve premature mortality in the U.S. could not be achieved on current trajectories by 2050. It would take well beyond 2100 before that eventuality could be realized. The conclusion of that commission is that the United States is not reaping the benefits for the health of its citizens from the enormous resources it invests into health and medical research. Bottom line, a reset is urgently needed.

But, as you can tell, I’m not an American. (Laughter.) And so instead of focusing on the domestic situation, which others can do far more eloquently than I can, I’d like to make a few remarks about the relationship between the United States and the rest of the world. First, America’s contribution to the quality of health care worldwide is second to none. I saw firsthand as a medical student, four decades ago, at Mass General Hospital the unparalleled standards of what American health care, at its very best, can be. And over the course of my lifetime I’ve only seen that premier position, as the best of the best, strengthened and enhanced. Largely because the United States remains the center of gravity for research-led innovation and advances in clinical practice. America sets the benchmark for quality of care for the rest of the world.

But, second, let’s also think for a moment about U.S. health-care institutions and research institutions—NIH, CDC, FDA, and others. They too have led the world in terms of research outputs, public health leadership, and medicines regulation. But a headline that appeared in October in Nature raised an important question we should reflect upon today. How long will the United States be a science superpower? Marcia McNutt, president of the National Academy of Sciences, was quoted in that issue of Nature as saying this, “U.S. science is losing the race for global STEM leadership.”

The reasons are complex, ranging from funding to perceptions about how welcoming the United States is to talented foreign scientists. But whatever those reasons are, the reality is that China is now consistently outperforming the United States in terms of research papers, Ph.D.s, patents, and high-impact work. It’s true that in the realms of biological sciences and medicine, the U.S. has maintained its edge, but for how long can it continue to do so? One lesson of the global burden of disease is that progress is not inevitable. Progress depends upon continuous, intense, and intentional commitment to the goal in question. Is that commitment still present?

Third, investment and financing for global health. As Joe Dieleman and his colleagues point out in their assessment of the American role in global development assistance for health in this special issue, no other country has made such a massive commitment to global health in modern times. His team’s estimation, $278 billion U.S. since 2000 for low- and middle-income nations. The Global Fund, PEPFAR, President’s Malaria Initiative, Pandemic Fund, Gavi, multilateral investments—all of those benefit not only the rest of the world, but they also benefit America in terms of its economy, its security, and its role as a global leader. But the global financial climate, the proliferation of demands and needs, distractions such as wars, climate crisis, means—and the challenging domestic agenda—all mean that America’s commitments to global health are fragile, at best.

And those three domains—America’s preeminent position in terms of quality of care, the quality of its institutions, and its investments—all those combine to determine America’s political leadership in global health, America’s voice in the world, the sum total of its activities in health. Yes, money is important, but it’s much more than that. The programs that the U.S. invests in to deliver health services, the technical assistance it provides, global health diplomacy, research partnerships, the role that you play in governance and standard setting, your contributions across a range of issues—AIDS, TB, malaria, maternal-child health, nutrition, family planning, reproductive health, global health security—all of these in seventy-nine countries worldwide, means that the U.S. is the world’s most generous contributor to global health, representing around a third of all international health assistance. It’s work that is crucial in creating the conditions for international cooperation, peace, and security at home and abroad. And it is our task, surely, to protect that role and to strengthen it, as a new administration comes onboard in the new year.

But, to conclude, in Samir Puri’s 2024 book, Westlessness, he argues that Western nations are ceasing to be the dominant forces that they once were. I quote, “We have just lived through the American century. It cohered in the twilight of European empire. And in turn, we now consider its own twilight.” He’s not suggesting that American influence will recede. He’s suggesting that it needs to be rebalanced, readjusted. Influence in the future will be shared. Power will be contested. The future is and will continue to be more diverse. America and its Western allies will need, he explains, and I quote again, “to actively maneuver to preserve their global influence.”

The theme issue that you have before you offers one platform for these discussions and debates. And if there’s one, only one, conclusion that I draw, it is that there is a tight, inextricable linkage between the health of Americans at home and the health of America abroad. As the pandemic showed, a country’s health security depends on the existing health of its people and the robustness of its health and public health services. My contention is that flourishing domestic health in the U.S. is a precondition for a sustainable, credible, effective, and respected role in global health and global health security. And that is the equation for the coming administration to solve.

It’s now my pleasure to invite John Monahan, my very, very longstanding and good friend, to invite the panel up to the stage for discussion. Thank you so much. (Applause.)

MONAHAN: Well, thank you very much to both Richard and Tom. Richard, as always, keeps us—sets our goals big, and keeps our eyes on the global perspective. Tom, as always, thank you for organizing such a terrific event. I think you’ve absolutely set the table for the conversation that we all need to have.

As Tom mentioned and Richard mentioned, I’m John Monahan. I’m a professor at Georgetown University, a member of CFR. I just would note, I think it’s terrific that both CFR and The Lancet have partnered around today’s project to take a look—take a deep dive at the health of the American people. This gives us a chance to look more closely at U.S. health, but critically from a comparative lens. How do we—how do we fit into a larger world? And also to consider the U.S. role both domestically in health and internationally. And we’re also—as referenced by both Tom and Richard, we’re at a turning point. We have a new administration coming in. While health was not as prominent in this last presidential campaign as it has been in years past, it’s very clear that President-elect Trump and his team have promised major changes.

The details and the contours of those changes, I think, are still to be determined. But we’ve seen, by some of the early, I dare say, controversial nominations to Department of Health and Human Services that there’s a signal for change. Again, I think the details are to be seen in the days and months ahead. So that’s why it is so timely that The Lancet has put together this extraordinary compendium of articles that really take a look at the role of U.S. health, both domestically and globally. And the best thing for this audience, for everyone here and on Zoom, is that we have an all-star team to help us think this through today.

Again, I will—I will not—you should have all the bio information. We would take the entire session going through the bios of these extraordinary people. But just as a quick reminder, Dr. Rebecca Bunnell is the principal deputy U.S. global AIDS coordinator. She is second in command of a program which has a $6 billion budget and operates in fifty countries around the world. Dr. Victor Dzau is a longtime friend, president of the National Academy of Medicine, a distinguished scientist and physician. He also is chancellor of Duke University and the head of its health system.

Dr. Mona Hanna is the associate dean of public health and the Mott endowed professor of public health at Michigan State University. And she led and has founded a pediatric health initiative. As Tom referenced, she was very actively involved in the Flint water crisis. Somewhere in the ether is our friend Chris Murray, who is the professor and chair of health metric sciences at the University of Washington. We can see him on our screen in front of us. His team is responsible, as mentioned, for so many of the papers in this remarkable compendium. But he is the director of the Institute for Health Metrics and Evaluation. So, Chris, thank you for joining us online.

So we’re going to jump right into it. We can spend a whole day on this remarkable compendium, but let me—let’s start with an opening question. Which is, I really would like all of you to comment based on your experience, based on this remarkable edition of The Lancet. What would be the biggest issue that you see facing the U.S. in health domestically? And what should we be thinking about in terms of our global engagement? And, Chris, just to engage you with us across the country, I thought maybe we’d start with you. And especially based on some of the papers you and your team have put together, if you could maybe give us your take about where we are. There’s so much to do, but how do we focus?

Chris.

MURRAY: Thanks very much. And apologies for not being there in person. Plans didn’t go to what I thought. On the domestic front, it’s sort of—there’s an element to how poor the performance of the U.S. is that it’s sort of even beyond expectations. You know, we just—every year, relative to other countries, we get worse and worse. And so you have to look for explanations that account for other countries getting better, while we sort of flatline and, in some parts of the U.S. and some groups in the U.S., things get worse. Part of that story—I mean, there’s—and I think there’s no one answer. But I think the nexus of obesity, diet, physical activity, that clustering and the associated diabetes and other noncommunicable diseases is an important part of the story. Certainly not all, but it’s very hard to imagine an explanation of how poor the U.S. is without addressing that nexus.

And on the—on the global front I think that the biggest issue is how do we sustain this incredible role the U.S. has had in financing a diverse array of maternal and child and, you know, The Global Fund programs that have had real impact. And so I think there’s—you know, it’s the combination. I think Richard’s comments about the linkage between the U.S. not as a leader for domestic health but as a leader on global health, is worth, you know, thinking about carefully. But, yeah, that would be my first take on the big drivers. Now, of course, the manifestation of that is these enormous—on the domestic front—is these enormous disparities that, unfortunately, despite explicit policies to reduce disparities, they’re actually going the opposite direction. We’re getting larger disparities in the U.S. And they’re growing over time. And there’s this complex interplay between those and drivers like obesity, diet, and physical activity.

MONAHAN: Thanks, Chris.

Mona, do you want to?

HANNA: Yeah. Thank you. It’s wonderful to be here.

You know, I think what really kind of was brought home to me after reading this amazing special edition—you guys should all read it—and the comment today, is really this kind of concept of exceptionalism. Like, we are doing exceptionally bad, as we’ve heard. (Laughter.) Like, really, really exceptionally bad, in so many different measures. And we heard about obesity and chronic diseases and life expectancy. And it’s bad, bad, bad. And I think for me, as a practicing pediatrician, as somebody kind of who practices in the poorest city in the nation, who’s really been troubled with so many kind of health inequities for a long time, I see the numbers and the statistics at the end of life and it reminds me that we need to begin working on this at the beginning of life. And that we do so much work Band-Aiding, and we spend so much money on this sickness-based system.

We fund, we invest, we spend so much money paying for health care, and doing research, and all this stuff after the fact, right, that we need to continue to focus earlier and earlier and earlier. And that’s my work as a pediatrician, is prevention, prevention, prevention. That’s my work in public health, be it giving a vaccine, or anticipatory guidance, or injury prevention. Everything that we need to be doing we do—we fail to do early on in life. So I think the biggest issue domestically is our failure to invest in prevention, our failure to address the massive socioeconomic inequities that make it impossible—near impossible for certain children to grow up in certain ZIP codes to be healthy and successful.

So I’m going to be that person that keeps pushing us back to focusing on early of life as possible and focusing on prevention. And I think that’s also something that we can—we can look at what needs to be—what needs to happen globally. I think this is something we can learn from in terms of our global partners, and something we can also export in terms of investing in early childhood, and also paying attention not to what happens in doctors’ offices and hospitals, but really looking at healthy communities and healthy environments, and the milieu that is needed to make sure that kids will grow up and not be obese, and not have chronic diseases, and not have those life expectancies that are so disparate.

MONAHAN: Thank you, Mona. That’s terrific. Maybe just starting, maybe, with more of a global perspective, Becky, do you want to?

BUNNELL: Sure. And, again, thank you, John, and thank you to colleagues here for organizing this really important discussion.

I think if I were to choose one issue, both domestically and globally, I think it is to really make public health a major obligation for all nation-states. And we’ve got to get off the kids’ table and be at the real dining table and be part of all the discussions that need to be happening, both on the economic side and on the health side. I think we have much in place to make that happen and to help advance that. You look at the State Department—I’ll start there, where I sit, and I see other colleagues here from the State Department. A year and a half ago we launched a new bureau, the Global Health Security and Diplomacy Bureau. This is a bureau that specifically signals that the U.S. has made health, and global health security and diplomacy, an official component of our policy and diplomatic efforts—something no other nation had done.

And I think it positions us not only to successfully work in the countries where we have, you know, emerging infectious disease threats or other public health threats, but also with all nations, including those who are higher income and may be able to help shoulder the burden of and cost of some of those threats. Different parts of our federal government have also really done a lot of work on strategy, not only in the State Department, where we’ve launched a strategy—several strategies around this. I think HHS yesterday launched a global health strategy. NSC has launched an overall playbook around global health security. We’ve done a lot of the thinking around this.

And importantly, from my perspective, we have examples where we’ve done this and had success. So PEPFAR is a premier example of this, where we did make this embraced commitment to really make the investment, and we’ve had tremendous results. So I think we can talk more perhaps about what needs to come in the next few years, but I think we’re really positioned to advance and have public health be a centerpiece of what needs to be part of all nation-states’ obligations.

MONAHAN: Thank you. I love the idea of public health being at the grownup table. That’s a good metaphor.

Victor, you wrote a terrific piece in The Lancet edition to try to bring some of these threads together. Love for your thoughts on this.

DZAU: Well, let me first thank Richard and Miriam. I mean, they had a brilliant idea. They called me and say, we want to do this. I said, are you sure? (Laughter.) And, you know, because we couldn’t predict where we are today, but all the more timely for putting this together. And I thought the articles in there—and of course, you know, I can imagine all the U.S. officials are not at this table, and for obvious reasons, but they all contributed. I think it’s really important. And so I said to Richard and Miriam, they’ve been extremely resilient in getting this—all of this together. But, you know, this is such an important conversation. And, Tom, thank you for hosting it, as always. Really, your home is a really important area for all of us to think about this issue.

Boy, there’s so much think about. And Richard pointed out, quality of care, the institutions, and the investment are the three areas. So let me think about all these three areas. Yeah, I was in training at Mass General and others, and I used to think, boy, we have the best quality of care. But, Richard, how do you defined quality these days, right? Yes, we have great technology. We have great doctors, to be sure. Our system is really broken. And I can’t say that we have quality in the broader sense, maybe quality for individuals who have access to this. Institutions. I want to talk a little bit about research, because, you know, this table, we talk about health care but, as you know, we launched a report on U.S. biomedical research enterprise. And in fact, we pointed out some of the biggest problem, right? Great advances, huge monetary commitment, as Mona just said, but I think in our case it’s actually not achieving the outcomes. Not that we don’t have Nobel Prizes and all that stuff. And why? And, of course, investment. All these are linked.

So my main issue, my feeling is, disparities. And people like me, I’m in my seventies. (Laughs.) And Richard and others are going to be just fine. (Laughter.) So what is the best—and you Tom, and others, John. So what—why are we having such bad outcomes? Because we have huge disparities, right? And that’s where the root cause is, in my opinion. And these disparities are driving everything. No matter how much money you put in, you don’t address disparities you’re going to end up with this outcome, which is so terrible. And I think Chris Murray at IHME pointed out very clearly. So we are a very diverse country. Most people think we are more homogenous, but we’re very diverse. Look at this panel and look at people in this room. And we have fifty states. We are very diverse. And everybody thinks Washington is where everything should happen, but so much has happened locally in the state. The question is, how do we actually get down there to address this issue? To me, that’s a big, big issue.

I think systemic and structural factors are key. So we have now been working for a year at the National Academy in coming up with a series of nine papers, ten to be exact, of which eight are population specific. So we’ve asked African Americans, Asian Americans, Latinos, and American Natives, and on and on and on, each one writing a paper, getting the experts together, to say, what is the issue here? And I think the systemic and structural factors are just profound when we look at the history of United States or where we are today. Until we address those issues, we can do all we want. We can sit at the dinner table. But I think these are fundamental social issues that we need to address. I think that’s a key issue. So I totally agree with investing in public health. I think public health is the way to go because it really thinks about the health of everyone, and also addressing systemic issues. I think we really have to bring in so many social issues, social equity, public policy. We’ll never get there until we address those issues.

And then I think—two other points. One is on the research side. Richard, we had this paper with a blue-ribbon committee that says, look at U.S. investment. Sure enough, China is catching up, but we’re still leading by far. And the accomplishment—I mean, today I think about, wow, I’ve been giving a talk about the Brave New World. And Huxley in 1930 says, you know, we can do genetic engineering, we can do psychological manipulation. We’re all here. We have all those technologies today. But, question, does everybody have access to technology and are used for proper reasons? So in our research, Richard, the major thing we said about, outcomes are bad no matter how much money you put into it. What you’re missing is the social sciences, the last mile which we need to—(inaudible). So in addition to social policy, our research and our practice have to be really focused on those disparities.

I think that U.S.—I’m actually confident that U.S., despite the changed administration—we remember last time we defunded WHO. We may do it again. But most of us hang in there. We spoke up against this. And here we are, still highly committed. I feel that U.S. will always be committed. The real question is, how and how much, right? And that’s why PEPFAR is such an important issue. So, Richard, I think we—I do think—I’m confident that our leadership, in terms of global investment, it may diminish some with different administration, but it’s going to be there.

My final points is on PEPFAR. So, yeah. So we had a workshop in September, Rebecca and I see Jimmy Kolker, others there, right? John Nkengasong asked if we, as an academy, can do an independent workshop about HIV and AIDS, because 2030 SDG and 95-95, we’re not going to meet it. And then, of course, without the reauthorization of PEPFAR, what’s it going to look like? We had really major players. We had the U.N. AIDS Director-General Winnie. We had, you know, Mark Dybul, we had Jimmy Kolker, Jim Kim, Tom Frieden all the previous PEPFAR people. What we came together to say would be the following. One is, we must commit to—actually, to the PEPFAR principles and to really treat and prevent, all together, to end HIV. We need, of course, reauthorization PEPFAR, but we need sustainability.

Because most of us feel in our gut that PEPFAR is not—the way it is, is not going to go on forever. So that’s why we need to think about how to get sustainability from regions where regional countries have committed a percent of their commitment to PEPFAR, 10 percent which has not really been realized. And then Jim Kim talked about innovative financial model all together, so you can see a long-term goal for PEPFAR. And of course, now with injectable, so important to invest in it so that we can really look at prevention and maybe end it all together. So I think we’ll continue to lead those kind of thinking. Certainly, I’m committed to—as I told Rebecca—convening these groups to continue this direction. So I would say that at least you can trust many of our voices, people in this room, I see lots of friends here, to continue push for supporting and recognizing U.S. disparities and global disparities.

MONAHAN: Thank you. As Victor, we all want to be in as good shape as you are at this point at this point. (Laughter.) No, but I—but let me—let me transition. I think Victor’s—I think, before we move on to broader issues, I guess I’d like to dig a little deeper on the issue of disparities. I mean, this is not—as impressive as the papers were in this compendium, this is hardly new information that the United States—that we have had continuous, you know, going back really throughout our history, disparities based on race, gender, geography, ethnicity. Though, obviously these papers really strike home that we aren’t making progress. I’d also say that we’re coming off an administration that, for the first time at least in my life, it made equity in addressing these issues front and center.

And so I guess one question is, we transition to a new administration. What sort of specific policies would you recommend at the federal level? And I hear you, at the state and the local level as well, but what can we do in this political environment that is practical, is actionable, and you think could make a difference? I appreciate the work that the National Academy is doing and that Chris is doing. But I guess I’d invite us to dig a little deeper. Chris, maybe I could throw it to you to start us off, but I really think everybody here, it’s—I think if we don’t think about actionable ideas, I’m afraid that we won’t get the attention we need.

Chris.

MURRAY: You know, from our point of view, you know, the group of us working on a number of these papers, there’s a few avenues to pursue, sort of immediate, actionable avenues. The first is, when you look at the really strong linkages between educational attainment and health outcomes, that then leads you back to sort of—(audio break, technical difficulties)—educational outcomes begin. And they begin very early. You know, in early childhood. And so it seems like you really have to start addressing, even more than has been done in some communities, addressing the gaps that that open up, even before primary school. So that’s one strategy. And there’s some models to look to. There’s a question about how to finance that nationally, or more broadly.

The second one is the sort of theme around spending a lot more money on public health strategies and investment in risk management. Because even though we know there are disparities, there are addressable things around diet, physical activity, around high blood pressure, around smoking, that will make a very big difference. And, you know, those are sort of—while we’re working on addressing the sort of core disparities in society, I think there’s a lot of opportunity to spend quite a bit more on trying to address those risk factors.

And then, on the last one, is the platform for many of the preventive strategies of reaching communities, of outreach, does require a broad functioning or access to the functioning health system. And even though we spend so much, we’re not particularly good at giving access to primary care. And so there is a—you know, there are movements in different states around community health workers, of different ways to engage people and bring them into getting access to prevention, that I think are also part of our sort of actionable components to how we might address our general slide in the numbers that’s gone on now for forty-plus years.

MONAHAN: Chris, thank you. Great.

Mona, maybe I ask you, because I think it really builds on your experience.

HANNA: Yeah. So we were super excited to have an article in this feature about child cash transfers, which are an actionable thing that we can do to address disparities. So once again, I’m a practicing public health pediatrician in the poorest city in our nation, where I treat disparities every single day. A child born in Flint has a twenty-year difference in life expectancy than a child in another part of the county that I practice in. Not unique to where I am. This is part of—this is seen across the nation. So frustrated with this, frustrated with treating the consequences of disparities—be it failure to thrive, or childhood obesity, or chronic diseases, or mental health issues—we created a solution. And we call it Rx Kids, a prescription for health, hope, and opportunity. And we are prescribing cash to every pregnant mother and every baby in the city of Flint, everybody. It is the nation’s first universal, unconditional maternal-infant cash prescription program.

It is a solution. It started in Flint to address every single one of these disparities. And it is not rocket science. It is built on global evidence. It is built on massive global, and also very much domestic, evidence, from the Expanded Child Tax Credit, which lifted millions of children out of poverty and improved a bunch of different out different outcomes. That was not renewed. So when that was not renewed, we kind of realized, oh my gosh, the U.S. can do big things. Like, we can eliminate child poverty. We can cut it in half, like was recommended by a National Academy report a few years ago. We can do big things. And so that inspired the solution in our city to prescribe cash to every mom and baby. This started in January. We have prescribed over $5 million to every pregnant mom and child. We have a near 100 percent uptake, right? We’ve had no evictions this year. We have improved food insecurity, improved housing insecurity, improved prenatal care, improved birth weight, improved, you know, all these different, wonderful outcomes, as expected.

So it’s time limited. It’s for moms and babies. It is something that has bipartisan support. We’re spreading to the Upper Peninsula in Michigan, which is very conservative and racially, you know, different than Flint, with lots of bipartisan support. Libertarians love this kind of stuff. And once again, we also have, you know, had inklings from J.D. Vance, for example, wanting to expand the child tax credit. So I am a physician. This is called Rx Kids. This is medicine is money. I partnered with a social scientist who knows how to deliver cash, I know how to take care of kids, to create this prevention-driven, you know, upstream solution to all of these disparities that we’re talking about. This is something that is absolutely replicable. And we talk about it in this special issue.

MONAHAN: Thank you. And I love the idea of broadening our vision about how we address disparities outside the health sector.

Victor, I think you had your hand up.

DZAU: Well, I mean, what Mona is doing is really impressive. And I keep asking myself, why don’t other people see it the same way?

HANNA: That’s right! I know, seriously!

DZAU: But that’s the problem, right? We can talk all we want. You know, this is a group of experts and intellects, and we want to do good. But why doesn’t the public see it this way?

HANNA: They are starting.

DZAU: Well, I hope so, because I think we blame the politicians. But politicians are elected and sent to Washington. And you look at the last election, the presidential election, the U.S. public has spoken. They don’t quite see it the same way as we do. We, if I can use the word loosely. I think that’s the issue. I think if I were to say what we do next, spend a lot more time in the community and understanding what they’re saying. Spend a lot more time trying to really understand the psyche, the kind of thinking, the issue of trust, many other issues, so that we can actually serve them. I think we need to spend less time sitting in our chair thinking about what needs to be done, versus out there trying to understand what people think we should do, and then combine, you know, our expertise, if you will, of thinking along with what’s needed.

To me, that’s a fundamental issue, right? So we can talk about education. Totally agree. From birth to—well, I won’t say death—(laughter)—birth to somewhere. But the question is, who controls the education? And look what’s happened in education. Every local area, every state. So until we really understand the American individualism at this point, and what they care about, and they think that we are—they believe that we are actually working on their behalf, that’s so important. I believe this, Trump won because he’s speaking their minds, right? Right or wrong. And I think it’s time that we don’t sit in our room to think about what we can do. It’s what really is needed out there. So certainly at the Academy, we’re really changing a lot of things. When you say community, you just think about, well, you know, this is a poor community, marginalized population. But we need diverse opinion. So certainly, engaging different opinions is important—Republicans, Democrats—but all for the right reason. It’s all about health and wellbeing of the population.

MONAHAN: Well, obviously, I agree with the idea of replicating Mona in multiple communities around the country, but to, Victor, your point, I think we have to listen. I mean, and I think that even the language of us and them, we’re all—this issue is an American issue. And it includes Democrats, Republicans. It includes people in different parts of the country. We’re not going to make progress on these structural issues unless we engage. I totally agree with you.

HANNA: If I could also add.

MONAHAN: Please.

HANNA: So, you know, this work that we’re doing, in its essence it’s about rebuilding the social contract. It’s about rebuilding the relationship that people have with government and with health care. I see it as a tool to even rebuild democracy, because people are—they get these cash prescriptions, and it’s funded by public-private, it’s government, it’s philanthropy, it’s everybody. And there’s a note from the governor that comes with every cash saying, we love you. We’re so glad you’re here. We can’t wait to see what you do when you grow up. And it’s built on this dignity. It’s built on freedom and choice. So and we’ve actually assessed the outcomes. And people have more trust now in government and more trust in health care, because they see the benefit of institutions working for them. So how do we create systems and programs, interventions, where we can rebuild that trust in health care, in health, in government, so people want to be part of these processes in a very kind of science, prevention-driven way?

MONAHAN: So, maybe building on this point about trust, Mona, and I’d ask everybody here, not only do we have trust issues in addressing things like disparities, but we’ve come out of a pandemic where, I think it’s fair to say, the public health and science community lost ground in terms of trust, at least in our country. I think it is true in others as well. So given where we are in addition to sort of innovative programs like Mona’s, and listening, to take Victor’s point, where do we go? Like, where does the public health community, maybe a little—with a little humility at this moment—go to rebuild trust with people who not only are maybe ignoring, but actually are maybe even hostile to the idea of the direction coming from public health agencies? Chris, do you have any thoughts about where we could go from here in terms of trust?

MURRAY: Oh, a lot of thoughts, particularly about COVID, but—or during the COVID pandemic, when we were pretty engaged in sort of public narratives about science. But I think that the core problem comes when we, in public health or in medical science, say things to the public with good intent, but not exactly following what the science is telling us, right? There’s sort of an editing function going on. And then that builds—and then if it turns out what we said wasn’t exactly right, that builds a lot of skepticism and distrust.

So I think there’s a—there’s going back to the basics, not altering the narrative for—you know, trying to encourage good behavior or healthy behavior, and trying to help the public understand that we don’t always know the answer on everything, and that as new data comes along our story, our narrative, or our priorities will evolve, as they should. And we’re not at all very good at communicating that and bringing the public along with us. There’s this desire to, you know, simplify, and then communicate things that may or may not be exactly what the evidence says. So, yes, we’ve come out of the pandemic, unfortunately with a pretty big ding on the credibility of us in the scientific community. And we need to rebuild that trust. And that has to start with honesty about what we do and do not know.

HANNA: I can say a little bit.

MONAHAN: Please.

HANNA: So my community has had a longstanding kind of lack of trust in institutions, that worsened, obviously, with the Flint water crisis, where people were told that their water was OK when it wasn’t, that worsened with the pandemic. But, once again, it was on shaky ground before because of these systemic inequities that made it really hard for people to be healthy. I think a lot about trust. Our lot of our work is kind of grounded in rebuilding trust. All of our work that we do is community partnered, community driven. We do a lot of listening. We have community advisories. I have a parent partner group. I have a group of kids that advise me. They’re called the Flint Justice League, and they’re just a group of kids that tell us what we should be doing.

And this Rx Kids program was driven by our community saying, hey, you’re doing all these great things. You know, we have early childhood programming, and we have trauma-informed care, and we have, you know, nutrition programs. But, like, we’re—it’s still really hard to get by. So I think trust happens when you are, you know, grounded, when you are actively listening, where you’ve built the infrastructure, where people have seats at the table and there’s representation. And that’s also part of that kind of self-determination and participatory democracy. So all those are critical elements of trust.

I think one more element, and there’s an article in the special edition about this, it’s about kind of justice and reparations almost. Kind of that we have to—you know, I think of kind of what happened in Flint as, like, an open wound, this injustice that happened. And without healing—we have to have some element of justice, accountability, acknowledging the dark history that has often happened in certain communities, the injustices that we have never kind of acknowledged and had some sort of kind of—you know, some sort of reparations for. So I think that is also a part of—an effort that needs to happen to rebuild trust in the communities. That you care, that you recognize what has happened in the past, and that we’re doing something to address these longstanding systemic inequities.

MONAHAN: So let me switch a little bit to affordability, if I could. You know, one of the—you know, one of the findings of all these papers is that we spend an enormous amount of money on the health-care system, and we don’t get the outcomes that we want. On the other hand, there’s an active debate, I think, in Washington, as we imagine the Congress is going to consider the extension of the president—President Trump’s tax cuts. There is a—he has indicated that he would clearly want to protect the Medicare program. It opens up questions. And there’s active discussions on the Hill about restructuring the Medicaid program. Not only maybe block granting but adding work requirements, which would seem in the opposite direction of the sort of RX for Kids strategy. It also—there’s also questions about the extension of the subsidies that make coverage that’s available through the Affordable Care Act. Without those subsidies, will the program remain as affordable as it is?

I guess I would ask everybody here to reflect a little bit about the affordability of the health-care system. I think to Victor’s point, one of the messages, at least for me, in this election was people are very clear that they expect their government to help deal with the cost of living. And one of the biggest chunks of uncontrolled cost in people’s lives is health care. So I guess just some thoughts about how our health-care system, with these debates on the horizon, how should we be thinking about affordability?

DZAU: (Laughs.) This is some of the biggest—

MONAHAN: I’ll just ask a lot—I’ll ask a lot of big, tough questions. (Laughter.) That’s the advantage of being the presider. I just get to ask and you guys get to answer.

DZAU: I think, at the end of the day, our country has to reconcile between, an innovation economy versus mission-driven economy. What I mean is, you look at so much of where we are leading the world in innovation. I will continue to say, despite what’s written, and others, that we are leading the world. I mean, look at all the discoveries, all the drugs, all the devices, you name it, right? But I think the big issue for me is that—one is, this is really a market-driven innovation, right? Things that can cross the valley of death, first one, really is there. But I think it’s driven by the opportunity to have a lot more market. And those that don’t make a market criteria are not going to make it. So that’s a big issue.

Now, are we ever going to say these drugs are too expensive. Are we going to say, the structure of many middlemen, PBMs, is too much? Are we ever going to address some of these fundamental issues is the question, right? At the same time, I think we all believe that, obviously, there’s a lot to be done in mission-driven innovation. The question is how do you meet somewhere whereby we continue to lead but that we don’t actually end up only doing things which are a market opportunity, and that we charge whatever we want, right? And I think if you look at the whole system, in many ways, we’re successful. We’re the most innovative country in the world because of our market capital approach. At the same time, we leave a lot of people behind. I do think we need to reconcile those issues in a big way, right?

MONAHAN: Mona, do you want to?

HANNA: Yeah. We need universal health care. This is a—you know, the medical industrial complex is profit driven. It’s I—you know, it has benefits for a few, but a lot of folks are left out. We need to invest in public health, massively. We need this massive kind of reset of what we are financing and who are we financing it for. So there’s a—you know, there’s a lot that we can do. I do not like when we kind of have this scarcity mindset. We only have this much money. We can give a little bit to WIC, and we can give a little bit to the—you know, the poor people here. No. You know, there’s a lot of other big buckets of money. We also fail to look at kind of societal savings.

In a program like Rx Kids, which is actually a very small investment in moms and babies, has a massive return on investment when you look at, for example, economic productivity later in life, and decreased health-care costs, and criminal justice costs, and all these costs later on. So I think we have to look at things over a long term, look at those societal savings, but really look at who are these things benefiting? We operate—this capitalistic system that we are working in does not benefit our communities. It widens these disparities. I look forward to innovative and creative ideas. Look at subsidies for the food industry, I mean, I can go on forever. (Laughs.) There’s a lot.

MONAHAN: No, no, so we—so we have to reconcile capitalism and our—and a social safety net.

HANNA: (Laughs.) You asked the question.

MONAHAN: No, no I asked. I want to be—Victor, I want to go back to—Chris, I’m sorry, it’s hard—a little hard to—did you have your hand up? I don’t want to miss if you wanted to jump in on this.

MURRAY: Yeah, I’ll—I didn’t have my hand up, but I’d love to make a comment.

MONAHAN: Sure.

MURRAY: Which is, I don’t think—we should think about catastrophic health spending. You know, people being pushed into poverty from having to pay for, you know, large health-care bills is a really bad thing. And that is an objective for health policy and social policy in its own right. And years ago, we set up a framework at the World Health Organization around health systems and recognized that as an outcome that we should all care about, monitor, measure, intervene on. But I don’t think, no matter how much money and how much access to health care we make available in the U.S., we’re going to address the widening disparities and how poorly we perform in terms of outcomes to the rest of the world. We really are going to have to tackle head on some of these pretty challenging risk factors, particularly obesity, diet, physical activity, smoking. And if we don’t, we are going to just keep going on that trajectory. Which is not to diminish in any way the value of avoiding catastrophic health spending. But I think we need to see those as different objectives. And the cost of addressing those risk factors is probably a lot smaller than addressing this fundamental issue about, you know, affordable care.

MONAHAN: Mmm hmm. Great. Victor, did you have anything you wanted to?

DZAU: No, I was going to ask Rebecca a question. But let me say that actually, as Richard Horton talked about, this recent assassination, which is a travesty. But it may have woken up the public to say how bad our system is. This may be a great opportunity for us to say, we get it, right, let’s address this issue together. I think this should be not—we shouldn’t miss this crisis, if you will, to say this is what the public feels, which is one. But if you look at all the social media, people coming into this, and if you look at many other issues, as I said again, we’re not reflecting sufficiently the public sentiments. We need to do that, and take opportunity, in fact, to propose the changes needed to address their needs.

Rebecca, I think my question for you is the following: I thought that launching the Bureau of Global Health Security and Diplomacy was brilliant. And then, as you said, HHS (lawyers ?) and others have just launched a new, quote, “strategy,” right, on global health. What do you see going forward now? How can we help to continue the great work that you guys have started, right? I think that Jimmy was involved with the diplomacy issue about how to get more global health diplomacy. How do you look at—if you look at pandemic preparedness—but global health security, tell us what your thoughts are.

BUNNELL: Well, let me—let me—thank you for that, Victor. And I may even call on Jimmy or Hillary, who are here, to supplement. I want to talk specifically about PEPFAR, because that is—in the Global Health Security Bureau we have two sides of the house. And I’m on the PEPFAR side. We have others who are really focusing more broadly. Of course, HIV remains one of the most significant global health security threats in the world. And we need to make sure that we sustain the gains and lead to a sustainable future for the huge progress that we’ve had. Look, with PEPFAR, if you think about it, we’ve achieved—together with our partners, together with the interagency—absolutely remarkable progress. Twenty-six million lives saved, 7.5 billion—I’m sorry—million babies born HIV-free to HIV-infected mothers, eight million orphans averted. And many, many collateral benefits—decreases in the proportion of kids that are not in school, increases in GDP. I mean, just many, many ways that PEPFAR success has had benefits. Certainly, benefits in the COVID response, elsewhere.

But we are not finished. (Laughs.) Because we’ve gotten very far in controlling this epidemic, but we’re at a point where if we stop now we really risk losing a huge investment that the U.S. government has had, and huge effort. Let me give an example. If I—many of you who are physicians know this, but for those who are not—if I’m living with HIV, I’m on antiretroviral treatment, and I stopped my treatment, my viral load—which has been suppressed because I’ve been on treatment—will rebound in about five weeks. Today, we have over twenty million people on antiretroviral treatment through PEPFAR. And if we were to stop that assistance before we’ve reached a point where countries can maintain it on their own, we risk having literally millions of people die around the world. And I don’t think any administration would want that to happen under their watch.

And I think we have an opportunity instead to really build the sustainability of this program over the long term. And happy to talk a little bit more about we’ve got a really good sustainability plan in place. We’re moving down that pathway. And I think there’s a real opportunity over the next four years to show not only that countries can reach a state of disease control, but that they can kind of graduate to a point where they’re running those programs on their own, with minimal foreign assistance. So in terms of global health security, I think we’ve got to secure examples like that to show this is a use case, but a tremendous use case. That we can do this even for one of the most complex and challenging viruses in the world.

MONAHAN: Becky, let me follow up on that, and then we’ll turn it over to the audience next. Per our conversation last night, if you could say a few words about how you imagine sustainability. Obviously, there’s an enormous case for why PEPFAR has been so successful in addressing HIV. But sustainability is also a diplomacy agenda, how the United States engages with other countries. And I’d love to get your thoughts about how—and, just to be honest, when we think about the incoming administration I think that—from past experience from the first term, and I think will foreshadow the second—will want to be very clear-eyed about how America engages with other countries. How do we—are we clear-eyed about who’s shared responsibility or not? Who’s responsible for what? I’d love your thoughts. And then, Victor, I think you want to follow up. But just maybe a little bit more on how you envision this sustainability agenda playing out, as we discussed.

BUNNELL: Sure. No, thank you. Well, let me—let me share that, as we have been working on our sustainability plan and implementing it within PEPFAR, we talk about sustainability and we’re building sustainability across four domains. They include a political dimension, a programmatic dimension, financial dimension, and a partnerships dimension. It’s not just about the money. It’s about all of those things that need to be in place for long-term sustainability. So, for example, Ambassador Nkengasong is not here with us today because he is in Nigeria negotiating with senior officials, the heads of state and ministry of health, finance, in Nigeria to solidify their commitment to domestic financing for the HIV response in Nigeria. And we’ve done a lot of work on that front. And State Department’s bureau has been a very helpful platform for us to do that.

We are now embedding, in our—what we call the COPP, the country operational planning process, for the next two years, to be launched early next year, a whole group of measures that will help us move forward. They include a tailored co-investment agreement that all of the fifty-five countries that PEPFAR is operating in will have, to ensure that they live up to policy, financial, and other commitments. They include, on the PEPFAR side, a more efficient, simplified, and streamlined way of operating for us. And finally, as I mentioned, it includes us identifying the first group of early graduates from, sort of, this long-term commitment that PEPFAR has had, Countries that can now stand on their own, largely stand on their own, going forward. So I think we’re really excited about that.

You know, I can’t leave this topic without again emphasizing a few words of caution. One I mentioned already, which is this risk of viral rebound if we step away too quickly. A second one—and, again, a reason why the bureau is so important—is that our adversaries are right there on the sidelines waiting to kind of jump in where we might pull out. I’ll give the example of Namibia. Namibia is one of our countries where the country has done fantastically well in terms of controlling HIV. They’ll probably be one of our early graduates. We have reduced PEPFAR funding in recent years in Namibia as part of our glide path towards self-reliance. At the same time, we’ve seen a huge increase in China’s interest and actions in an area they had no interest in before, around HIV. They have, for example, stepped forward and put a plan to fund the Namibian National Public Health Institute, something that PEPFAR had been doing. They’ve just recently taken a group of Namibian HIV leaders to China on a study tour to see HIV activities in China. So these are signals that the diplomatic space is super important and needs to be part of our calculations as we move forward.

MONAHAN: Thanks, Becky.

Victor, did you have anything? Then I want to move to audience questions.

DZAU: Well, I mean, Rebecca used the word “sustainability,” and because there are many different interpretations of that. One, of course, is financial sustainability. When you actually survey heads of state in Africa and elsewhere, HIV is not on the top of the agenda. They rank it quite low. That means they feel that you can depend on this external support. By the way, PEPFAR has done a phenomenal job. You already cited twenty-six million, but also building infrastructure in different countries, right? And this whole idea now of, you know, community health workers, you name it, has done so much.

But I would argue sustainability has to be that countries have to step up and actually take some ownership. This is why I think that the new financing model has to be thinking about can we rely on U.S. at this level forever? And if not, how do you make sure that others step up to this, right, and make commitment to this? Because that would go a long way, in my opinion, in U.S. Congress and others. Secondly would be, really rather than assistance model, can we do a much better model of investment, and loan, and others, right? Jim Kim has some really brilliant ideas of how to move forward leveraging the World Bank’s great, you know, bond ability, and to say let’s all participate in creating a way to sustain it. I think that, to me, is more likely what’s going to happen in the future.

BUNNELL: Yeah. You know, Victor, I just—I wanted to share one quick quote, because we’ve really been working on building an understanding of this at the highest levels globally. And just about a month and a half ago I was in Botswana. We were meeting with the then-president of Botswana, President Masisi. And he said to us: You—speaking to PEPFAR, us representing PEPFAR—you saved my country from extinction. You saved our country from extinction. And we are very grateful. But we know that a friend at a time of need cannot be a forever friend. And a friend cannot take over the long-term obligations of the citizens of a country. And we are here to partner with you on sustainability. That is a direct quote from the president of Botswana. So I think we have been able to really build that understanding that you’re speaking to, Victor, of people realizing everywhere that we all have a part to own this. And leaders of countries need to own it as well.

MONAHAN: That’s a perfect place to, I think, turn this to the audience here. This is usually not a shy crowd, so let me see if—oh, I’m sorry, Chris. Did you want to—I apologize—do you want to jump in?

MURRAY: Yeah. I’ll just bring a little bit of the data to hand here. I think there is a very broad concern in many capitals in Europe and in the global health sector of the direction of finance is actually the opposite of what we’ve been talking about, namely less money coming from high-income countries to low- and middle-income countries, and some pretty clear indications that debt stress and other factors appear to be driving domestic resource mobilization down, not up. And so I think there’s a very strong concern that even though there’s a lot of political rhetoric, shall I say, about taking on the burden of financing these absolutely critical programs, we’re actually not seeing that in the data. And the data is very, very poor, to put that out there, but what data we do see suggests that we’re actually maybe going in the wrong direction.

MONAHAN: Yeah. So with that, I think let’s open it up. We’ve got about—I think, about ten minutes for questions. So I’d love to see if there are folks in the room. I know there’s some familiar faces here so I’m surprised if we don’t have questions. Why don’t we start right here, the middle table. Just introduce yourself. Remember, this is on the record.

Q: Monique Mansoura with the MITRE Corporation.

Mona, truly inspired by the work you’re doing there. And a couple of elements I just want to wonder about scale and innovation, right? It’s the innovation and the financing, right? An Rx for cash, with a letter from the governor that says I can’t wait to see what you’re going to become, if you pair that with sort of the metrics—and you’re talking about the enormous ROI, right? This is financial innovation, in a way, paired with, sort of, delivery and the tools and technologies of health care. So I think if you pair that with the work that Chris champions and the ROI, how are we really capturing that? We don’t have to overcome a capitalist or market-driven economy; you’re driving it, right? Because you’re recognizing, number one, the linkage with education and health. That drives enabling people to contribute to our security, to our economy, to our social fabric. So would love to hear more.

HANNA: Thank you. So the funding is a beautiful public-private partnership. We initially received a $15 million grant from the C.S. Mott Foundation, which is based in Flint. But to date we’ve raised over $100 million. This is the largest cash transfer program of its kind in the U.S. A doctor is running the largest cash transfer program. (Laughter.) So this is health. But the beauty is that we have public financing. We were able to leverage TANF dollars for the first time. TANF is the terrible consequence of 1996 welfare reform. It became state flexible block grants. States can pretty much do whatever they want with this, and by and large it’s budget fillers for states. States misuse this money. Remember the Brett Favre Mississippi scandal? A lot of wealth. So in Michigan, before Rx Kids, only 6 percent of TANF dollars was going to cash assistance. The intention of this money is cash assistance.

So we presented a different vision to the state of how to use TANF in a way that was preventative, science-based, prevention-driven, inclusive. In the past, it was historically very racially administered, very much discriminatory towards Black mothers. So this is kind of a new vision. The state bought in. And we were able to leverage a provision within TANF—this is my new favorite acronym—called NRSTs, non-recurrent short-term payments. So you can use TANF dollars for four months during an acute episode of need. Childbirth in the U.S. is actually the poorest time in people’s lives, throughout the life course. Towards the end of pregnancy, moms lose income, they come out of the workforce. Babies are expensive. They need stuff. And that dip in poverty persists until the first year of life.

Another big factor, policy-wise, is we are the only kind of Western country that does not have paid family leave. My mommas go back to work at four days of age. And it is just unbelievable. So this is the poorest time in people’s lives. So ACF, the federal government, agreed. So we are able to use TANF dollars for part of this. So it’s a beautiful public-private partnership. The economic piece, which is also—folks love, is these dollars flow back into local economies. This is a place-based intervention with money going back into local economies to revitalize them. So we are looking at assessing all these different economic measures as well.

MONAHAN: I think somebody else at the middle tables? And then I’ve got Jimmy and then, I believe, one—probably—it might be all we’re able to do—one in the back of the room. So, please.

Q: Great. Thank you so much. Thanks for this wonderful panel.

You know, in the opening we heard that the U.S. sets a lot of the benchmarks and baselines for health around the globe. And we also heard that kind of strong U.S. health presence is important for good global health. And even the title of today’s event. U.S. Health and Global Implications, kind of thinks about that normal trajectory of kind of the north to the south, or the high-income to the low-income country. We recently saw Marburg effectively contained in Rwanda in an incredible fashion, while the U.S. still continues to struggle with our management of bird flu. I’m curious to hear from all of you, what are the lessons that are lingering out in the global health ether that we could be taking back to use to improve the issues that we are talking about here today in the U.S.? Thank you.

MONAHAN: Who wants to jump on that? Anybody?

DZAU: You should.

MONAHAN: (Laughs.) I’d be happy—oh, please.

HANNA: So I think—oh, very quick. Child cash transfers are growing, proliferating. Seventy percent of countries have child cash transfers. The Global South is championing a lot of this, and that is being exported to the U.S. where this work is just beginning, very much. So that is one example.

DZAU: I think it’s really a global cooperative approach to this whole issue. Marburg as an example. Because for sure I’m involved with the 100 Days Mission, and CEPI has played a really important role. So there’s, in fact, a whole community of people, including U.S. leadership, is looking at how to respond to this rapidly. So there’s a lot of lessons learned from that. I don’t know how to say—you say, how does it compare to U.S.? Because I think, certainly, we’re all working together to solve this problem, and there’s a lot of lessons learned we can take from it.

MONAHAN: All right. How about Jimmy?

Q: Thanks. Just a—Jimmy Kolker. Just a disclaimer. I’m here as a CFR member, not as—speaking as a CFR member, not as Becky’s colleague at the Department of State.

But to answer a little bit of the question of the agenda, it does seem to me—to reinforce Richard’s point, and the one you just made about U.S. leadership—that the World Health Organization, the other multilateral organizations, are multipliers of U.S. leadership, of U.S. expertise, of the U.S. private sector’s ability to operate worldwide, and certainly of our institutions’ strengthening, and so on. But to do that, we need to be the best prepared government in dealing with multilateral organizations. And that’s why the bureau at State, HHS, reinforcing its diplomatic capacity, is so important, because we actually have to be there, lead, be the best informed delegation, show off what we’re doing, and be able to reach back to our technical agencies. So that’s one.

And but the second, in terms of what we should do, the linkage—when I was at HHS, and John had for a while too, and head of global affairs there, the question that other countries asked, and especially because, as you pointed out, our challenges in terms of quality access, social determinants of health are so similar. Who in the U.S. is working on this problem? And can we talk to them? And I think the hollowing out of CDC, and the sense of mistrust that was engendered in the last—in the COVID outbreak and attacks on CDC, are so counterproductive because the question of having a public health agency that not only deals at the state level with state departments of health, draws on that expertise, reinforces that expertise, gets best practices adopted and—if the system works.

But also, are the same people who can be called on to respond abroad to outbreaks and to be our technical partners with other countries that are looking to partner with the U.S., looking for best practices. We can’t contract for that, but to have the actual people who are doing that already on the payroll of the U.S. government is just an invaluable resource. And people in countries are not going to ask for the Chinese CDC to come in the same thought that they are of wanting the U.S. CDC if there’s actually a problem, or if they want to build their own institutions. And so I hope that we recognize how important it is to make the CDC a functional organization. And it’s absolutely the domestic-global link.

MONAHAN: I couldn’t agree more with Jimmy. Our domestic agencies are an enormous part of our global strength as a country. I think, Sam, we have time for one more? We’re done? OK. Oh, virtually, I’m sorry. Why don’t we go virtually. We should take someone from the—please.

OPERATOR: We’ll take our next question from Mr. Henderson.

MONAHAN: Please go ahead.

Q: Yes. Hi. This is Tim Henderson, Stateline News Service.

I just had a quick question for Mr. Murray. He was talking about fairly low-cost programs or initiatives on risk factors like blood pressure, physical activity. I was wondering if you had any examples of that, or if it has to be a foreign country that’s doing it, that we should be doing? You know, any concrete examples of that, what we should be doing there?

MONAHAN: Chris.

MURRAY: I think there’s lots of examples. I think the whole idea of looking for exemplars globally, which resonates back to some of the discussion we’re just having, and the answer to that’s going to be quite specific to the risk. You know, there’s successful stories or examples around blood pressure, physical activity—some, perhaps less overwhelming than the blood pressure management. And then on obesity, unfortunately, less of a set of simple, obvious success stories, although GLP-1s hold out some real promise of being part of the solution around obesity. And there, you can see some examples of that. Some countries have actually now authorized GLP-1s for everybody who is obese, and funded by government. And we’ll have to see what sort of population-level impact that has. But certainly on tobacco, certainly on some aspects of physical activity, and I think also on diet there’s some places we could point you towards where there’s exemplars for successful programs.

MONAHAN: Well, I think we’ve come to the end of our time. But before we do, I just want to ask everyone for a round of applause. I told you it was an all-star panel, right? (Applause.) I hope you got a sense of the richness of thinking of domestic and global health.

So I want to introduce Miriam Sabin, who is the editor of this remarkable compendium. And she’ll close us out.

SABIN: Thank you very much. Thank you, John, and to our panelists, for the excellent discussion today. And, in particular, thank you so much to the Council of Foreign Relations and Tom for partnering with The Lancet. I think it’s really important to keep moving forward and doing more in the future.

I just wanted to say a few things. As you’ve heard from our speakers and panelists today, the U.S. is facing significant health challenges domestically. And the U.S.’s role as a global health leader, which is and has been a source of undeniable impact, is now uncertain. I do hope that the content in this Lancet special issue will serve as a roadmap, as a briefing book to the next administration, but also to other federal, state, and local employees, and the policy advisors and civil society organizations that assist them. And I hope it is a call to action that we—that will be listened to. As we’ve heard today, health disparities persist domestically hindering every American from having an equal start. And the added insults, such as poor education, poor diet, environmental and racial traumas, effect life expectancy in ways that are deeply unfair to the American democratic project.

The situation is so severe that the U.S.’s national life expectancy has suffered. And other nations are taking notice. The CDC reported that in 2018, 71 percent of young people in the U.S. would not be eligible to serve in the military, in large part due to obesity. Another sort of interesting reflection on global health security that Dr. Bunnell had raised that issue earlier, in regard to PEPFAR. The U.S. is literally not fit for purpose. So what we said in our editorial in this special issue, I think, it really comes down to this: The health of a nation is a reflection of the health of an administration’s policies. And so I look forward to the opportunity to continuing to provide the best science and the best thinkers to helping inform our leaders, in partnership with the Council and many others of you in the room, to make smart, evidence-based decisions.

Thank you so much. (Applause.)

(END)

This is an uncorrected transcript.