In April 2009, just three months after Barack Obama’s inauguration, a new strain of H1N1 swine flu was detected in the United States. It eventually reached pandemic status, spreading to the vast majority of countries and killing more than 18,000 people. In September 2012, in the dusk of Obama’s first term, a new flu-like disease called Middle East Respiratory Syndrome (MERS) was described in Saudi Arabia; America saw two cases. In December 2013, a year into Obama’s second term, the biggest Ebola outbreak in history began in Guinea before spreading to 10 countries and killing 11,000 people; four cases reached the U.S. And by the time the epidemic officially ended in early 2016, the Zika virus had already started sweeping the Americas.
Infectious diseases are emerging faster than ever before. By encroaching into the territories of wild animals, we provide the sparks for new epidemics. By living in increasingly crowded urban areas, we provide the tinder. And by crisscrossing the skies in countless planes, we transform small fires into global conflagrations.
Obama had a good track record of responding to these threats, and channeling funds into fighting outbreaks around the world—as did his predecessor, George W. Bush. As Donald Trump prepares to become America’s 45th President in January 2017, the question isn’t whether he’ll face a deadly outbreak during his presidency, but when. And more importantly, how will he cope?
Outbreaks of disease are among the ultimate tests for any leader who wants to play on the global stage. They demand diplomacy, decisiveness, leadership, humility, and expertise—and they quickly unearth any lack of the same. “As far as I can tell, Trump has zero experience on this,” says Jack Chow from Carnegie Mellon University, who has worked at both the World Health Organization (WHO) and the State Department under Colin Powell. “If I asked him, ‘What is your stance on global health?,’ I don’t know what he’d say. I don’t think anyone really does.”
The bioethicist Art Caplan, from the New York University School of Medicine, envisages a quick slide toward isolation and authoritarianism. In a blog post that can only be described as pandemic fan fiction, he imagines that a lethal mutant strain of H7N9 flu emerges in China and spreads to America. A hypothetical President Trump responds with a quick succession of moves: He seals the borders with Canada and Mexico; he quarantines sick Americans; he declares martial law, builds detention-style camps for quarantine-defiers, and uses epidemic conspiracies to launch a trade war with China.
Future years will reveal whether the story is prophetic or far-fetched. For now, we can only speculate, using the president-elect’s own words and actions to predict how he might fare in an outbreak.
We know that international diplomacy is essential during large-scale epidemics. During the Ebola outbreak, the U.S. had to coordinate its aid with the WHO, other donor countries, and hospitals and laboratories in the affected countries. “The rhetoric about building walls and reneging on NATO calls into question how willing the administration would be to work with other countries,” says Elizabeth Radin from Columbia University, who works to improve health in poor nations. “And the phone calls to Taiwan and Pakistan call into question how effective they would be.”
Accurate public communication is also vital. During the Ebola outbreak, misinformation circulated more widely than the virus itself. People repeatedly and wrongly heard that the virus could go airborne, that victims bleed dramatically from their eyes and ears, that foreign health workers brought the virus to West Africa, that folk remedies were effective, and so on. These were all myths, and they encouraged practices that helped the virus to spread in affected countries, while fomenting panic in unaffected ones. They resembled the pernicious and long-debunked claim that vaccines cause autism, which has led to a resurgence in mumps, measles, and other infectious diseases, and which Trump has himself promoted.
If anything, this problem is likely to get worse, given America’s continuing struggle to deal with “fake news.” Inaccurate information can be easily seeded by foreign parties, and given weight and prominence by online algorithms. It’s arguable whether such misinformation made a difference between victory or defeat in the election, but inarguable that it could mean life or death in an outbreak.
The president-elect is hardly immune. Before, during, and since the election, Trump has had a strained relationship with facts, having repeatedly and reflexively lied about matters both large and small. He has reportedly failed to seek advice from the State Department before calling foreign leaders. He is avoiding most of his daily intelligence briefings, despite his lack of prior military or political experience—“I’m, like, a smart person," he recently said. Meanwhile, Lieutenant General Micheal Flynn, who will be Trump's chief counsel on national security, has shown a willingness to believe and push conspiracy theories.
These actions portray an incoming administration with a casual disregard for evidence, an unwillingness to tap into the expertise around them, and a reckless self-confidence. They suggest that, in an outbreak, Trump is more likely to heed his own counsel than that of the Centers of Disease Control (CDC) and other relevant experts. And he is likely to project that counsel to over 17 million followers.
Consider what happened during the Ebola outbreak, well before Trump announced his candidacy. On Twitter, he rejected evidence that Ebola is less contagious than is commonly perceived, since it can only be transmitted through bodily fluids. “He is very adept at using social media to rally supporters, but has also been inconsistent at sticking to message,” says Radin. “And ad-libbing, rambling, or flying off the handle can be very dangerous in an epidemic.”
Trump’s Ebola tweets also revealed how he might deal with an outbreak as president. He repeatedly called for the U.S. to stop all flights from Ebola-infected countries, even though no such direct flights existed, and even though flight bans don’t work. Several countries enacted such bans during the SARS epidemic of 2003 and the swine flu pandemic of 2009, but to no avail. It’s impossible to fully seal a country; when air travel is blocked, people will move by land, sea, and alternative routes that are even harder to track. And back in the source nation, fearful patients go underground, making it even more difficult to stop the outbreak and paradoxically increasing the odds that it will spread.
And yet, Trump’s predilection for clamping down and closing borders extended even to his fellow citizens: He said that American health workers who became infected should be stopped from reentering the country. “KEEP THEM OUT OF HERE!” he asserted. “People that go to far away places to help out are great-but must suffer the consequences!” As global-health researcher Jeremy Youde wrote, “This framework sees infected persons as an enemy to be contained and avoided rather than as people who need treatment.”
Given that mindset, it seems likely that Trump would be reluctant to send American aid to help with outbreaks in other nations. Indeed, during the Ebola crisis, when Obama sent the military to the affected countries to help with relief work, Trump called him “dumb.”
This should not be a partisan issue, and in the past, it hasn’t. In 2003, George W. Bush created the President's Emergency Plan for AIDS Relief (PEPFAR), which has offered antiretroviral drugs to almost 11.5 million people in sub-Saharan Africa (up from 50,000 before the plan began). With over $72 billion in funding since its conception, PEPFAR had been billed as the largest global-health initiative focused on a single disease ever undertaken. It “wasn’t really justifiable on grounds of national security,” wrote Eugene Robinson in The Washington Post. “The administration was motivated instead by altruism. It was the right thing to do.”
Obama continued that legacy “despite the most intense partisanship on Capitol Hill in living memory,” wrote Laurie Garrett for the Council on Foreign Relations. After a slow initial response to the recent Ebola outbreak, the U.S. eventually sent 3,000 health workers and 3,000 troops to the affected countries, and Obama secured an emergency budget of $5.4 billion to fight the disease in 2014. During the same year, he launched the Global Health Security Agenda (GHSA), bringing together nearly 50 nations and organizations to improve the world’s ability to detect and respond to new infectious threats. The U.S. has committed more than $1 billion to the program, half of which will be focused on Africa.
Hillary Clinton was poised to pick up that baton. “She had a track record on global health from her time in the Senate and as secretary of state,” says Jack Chow. “Global-health forces are very pro-Hillary and there would have been a deep bench of talent to play her philosophy out.” That bench includes Pardis Sabeti, a leading infectious-disease researcher from Harvard University who did pivotal research during the Ebola epidemic, and who had already been tapped to join the Clinton transition team. In the parallel universe where Hillary won, Sabeti would have joined a team that reviewed the Department of Health and Human Services, specifically focusing on the U.S. response to outbreaks and bioterror threats.
Meanwhile, back in this universe, Trump’s plans are unclear. When asked if he would commit to doubling the number of people receiving treatments through PEPFAR, he said, “I believe strongly in that and we are going to lead the way.” Then again, he also mentioned Alzheimer’s in his answer, so it’s possible that he was speaking generically about diseases and didn’t actually know what PEPFAR is. Keep your eyes on the president’s budget in February, says Chow. Look at the contributions that have been put toward PEPFAR, the GSHA, and other global initiatives. “That’ll be the first flash point.”
Protecting against pandemics is a profoundly multilateral problem. It requires cooperation and coordination between countries. “Viruses are global threats to humanity,” says Sabeti. “They’re everyone’s problem. In some ways, they’re the one unifying threat.”
But Trump stoked xenophobia and anti-immigration viewpoints during his campaign, and has since dug his heels into an “America First” policy. In the United Kingdom, the architects of Brexit used similar rhetoric. These inward-looking stances are at deep odds with the international politics required to stop local outbreaks from becoming pandemics. “If your desire is to keep disease out of your country, the best way to do that is to contain it at the source,” says Rebecca Katz, a co-director of the Center for Global Health Science and Security at Georgetown University. “That also just happens to be the best way to save lives in other countries as well.”
Should an outbreak breach America’s borders (or begin within them), the nation’s response will be determined by more than just Trump. His nominated secretary of health and human services, Tom Price, has experience in orthopedic surgery, but not infectious disease. His objections to the Affordable Care Act are well documented, but his stance on public health is not. And other key appointees, like the directors of the CDC, NIH, and USAID, haven’t been named yet.
Still, such agencies have experienced staff and institutional memories that persist beyond administrations. They can go about the business of identifying threats, tracing paths of transmission, and saving lives, without much political input. And even though federal agencies “are very important in providing centralized guidance, the real boots-on-the-ground work often happens at the level of state, county, and city health departments,” says Jill DeBoer, deputy director of the Center for Infectious Disease Research and Policy. That was certainly the case when the Ebola outbreak reached Dallas in September 2014. It wasn’t the CDC that saved the day, but a county judge, county epidemiologists, and other local health officials. To an extent, the experience that pools at the base of the medical hierarchy can compensate for any instability at the top.
Even so, the early months of a new administration are uniquely vulnerable. Consider the bioterror attacks of September 2001, when anthrax-laced letters were mailed to offices in the wake of the World Trade Center collapse. Tommy Thompson had been health and human services secretary for just eight months, and “didn’t seem to trust the career part of the government,” says Lynn Goldman, dean of the Milken Institute School of Public Health at George Washington University. “He didn’t trust the experts in government to talk to the public.” People heard wrong or confusing pronouncements, while postal workers didn’t get guidelines on protecting themselves.
“This kind of communication issue often happens during the transition,” Goldman says. She blames the frequent lags in appointing the middle-level deputies and assistant secretaries who connect newcomers at the top of the government with experienced health workers at the bottom. Expertise needs to flow quickly in an outbreak; in a transition, its channels are often dammed or diverted.
Even when the system works, it does so imperfectly. “There’s been some progress in our preparedness but we’re very far from where we need to be, especially in our ability to deal with biodefense threats,” says Pardis Sabeti. She envisages a worldwide network that regularly uses genetic sequencing to test for dangerous microbes, better standards for coordinating a global response, and pipelines for quickly developing effective diagnostic tests. “We need something that moves at light speed, and we don’t have it.”
That will take money to set up—and even in stark emergencies, funds for public health can be hard to find. This February, the World Health Organization declared Zika a global emergency. The Obama administration requested $1.9 billion to fight the disease but Republicans in Congress refused, arguing that the funds should come from the pot that had been set aside for Ebola. “Just because it’s two exotic viruses doesn’t mean that it’s the same thing,” says Goldman. “And just because we’ve quenched the Ebola outbreak in West Africa doesn’t mean that that problem has been dealt with. Politicians need to sustain funding beyond the time when they’re actually in a crisis.”
The problem is that public health, much like the microbes it combats, is invisible and unglamorous. “Most preparedness is a group of people sitting around a table day after day, talking through plans and scenarios,” says DeBoer. “Unlike a fire department, which responds to emergencies every week, in public health, we need to maintain our readiness for months and years.”
Would Trump do so? He certainly exempted public health from a proposed hiring freeze on all federal employees—a good sign. But there are less reassuring clues. When Trump was asked how he would “improve federal research and our public health system to better protect Americans from emerging diseases and other public health threats,” he prevaricated. “We cannot simply throw money at these institutions and assume that the nation will be well served,” he said. “Our efforts … will have to be balanced with other demands for scarce resources.” And the future vice president Mike Pence slashed Indiana’s public-health budgets to national lows during his time as the state’s governor.
During that same stint, Pence also learned a hard lesson. Last year, an HIV outbreak flared up in Indiana, borne on the needles of opioid addicts. Health officials recommended that the state set up exchange programs to swap contaminated needles for clean ones—but Pence refused on moral grounds. His decision allowed the epidemic to balloon. Amid mounting cases and pressure, and after a night of prayer, Pence relented—and the epidemic was halted. “It was a case of choosing evidence over politics,” says Radin. “Maybe the benefits he saw in that case would influence policy in the future.”
That’s the thing about outbreaks: They have the ability to scythe through ideology. “There’s a difference when you’re sitting in the White House and you have responsibility for the life and death of others,” says Goldman. “It’s very different than being on the outside and taking potshots.”