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United States election – a cruel blow for health

Hopes that the United States election would bring a more positive era for global health have been dashed by an election result that is too close to call, despite President Donald Trump falsely claiming victory in a clear threat to democracy.

Even if the count favours Democratic candidate Joe Biden in coming days (and The New York Times reports he is the favourite to win), a messy transition period is likely to stymie efforts to address public health crises ranging from climate change to the COVID-19 pandemic.

A weaker Democratic House majority and an unlikely path to flipping control of the Senate also pose challenges to any potential incoming Biden Administration, and a potential boost to any Trump Administration.

Up to 25 million Americans are at risk of losing health insurance through the potential invalidation of the Affordable Care Act in the Supreme Court, as the covonavirus continues to spread across the country, with nearly 50,000 Americans currently in hospital with COVID-19.

The election also underscores the mainstreaming of disinformation and misinformation, with tens of millions of Americans voting for a president who lies repeatedly and has a track record of undermining civil, scientific, environmental and health institutions. Meanwhile, supporters of the QAnon conspiracy have been elected to Congress.

Andrew Leigh

Speaking during a #CroakeyLIVE discussion as the results unfolded, Labor MP Andrew Leigh said many countries and also many Liberal politicians would be relieved if Biden was elected. If a secret ballot was held in the Australian Parliament, he said Biden would win about four-fifths of the votes.

Leigh warned that a Trump victory would embolden populists around the world and further damage international institutions such as the World Health Organization and the World Trade Organization.

He said:

My real fear is that eight years of damage to those institutions will leave them looking very different; and that the world that was built by Truman and Churchill after World War Two, of international institutions maintaining a rules-based order, could give way to something which is something much more fractured, fractious and less in the interests of a medium sized power like Australia.

Going to a world in which everyone is driven purely by self interest and might prevails is much more in the interests of large countries than medium sized powers, particularly if you comprise much less than one percent of the world’s population which we do.”

The #CroakeyLIVE was moderated by Croakey contributing editor Associate Professor Lesley Russell and James Blackwell, a Wiradjuri man and Research Fellow (Indigenous Policy) at the Centre for Social Impact UNSW and Visiting Fellow at the ANU’s Coral Bell School of Asia-Pacific Affairs.

Leigh appeared alongside Professor Adam Elshaug, Director of the Centre for Health Policy at The University of Melbourne who lives in the US, and Larry Irving, who was one of the principal architects of the Clinton Administration’s telecommunications and Internet policies and was elected in 2019 to the Internet Hall of Fame for his work identifying the “digital divide”.

Blackwell said he was very concerned about what could happen during the transition period should Biden be elected, as there would be nothing to hold back Trump who had hitherto been constrained to date by his desire to win re-election.

Elshaug, who lives a 15-minute drive from the White House, said the US was like a different country to when he had previously lived there under the Obama Administration. It was polarised, hyper-partisan and suffering an existential crisis.

He said it was “completely astonishing” that Trump had contested two elections without having a single heath policy position. Trump had repeatedly promised a “beautiful health plan” that would be released in two weeks’ time – that never eventuated.

Elshaug said:

What I find most frightening is that Donald Trump has now gone over four years and two presidential election cycles without holding a single health policy position.”

Adam Elshaug

Speaking from Washington, Irving said when autopsies were conducted on the election result, they would focus on the education gap in the US, “the biggest fault-line in American society”.

He said that 60 percent of adult Americans do not have a college degree. They formed Trump’s base and were influenced by the “Murdochisation” of the media and propaganda. He said:

We’re going to have at least two QAnon people in Congress…they believe a cabal of cannibalistic blood-drinking celebrities…primarily Democrats and Hollywood…are killing children for the purpose of sucking their blood and are part of the ‘Deep State’.

Who believes such insanity…How did my country come to this, how is this possibly a thing?”

Irving also expressed bewilderment that Trump had won in states with high COVID rates. “How is that possible?” he asked.

He said that if the US had the same COVID-19 mortality rate as Canada, “instead of 230,000 deaths, we’d have 80,000 deaths”.

A Democrat himself, Irving critiqued his Party for failing to engage meaningfully with Latino and Black voters. Democrats had lost Florida by under-performing with Latinos along the border with Texas:

If you can’t make a compelling story to brown-skinned people about brown babies being in cages and why you should be elected, that’s almost political malpractice.”

Irving painted a grim picture of the future for Americans with the pandemic. An upcoming Supreme Court decision on the Affordable Care Act could see 20-25 million Americans lose health insurance overnight, with a Senate that now was unlikely to help them.

Even if Biden was elected, it was not clear that his team had an effective pandemic plan, and delays to the transition period from legal challenges meant his administration would not hit the ground running.

“I’ve done two Presidential transitions,” Irving said. “I know how critical they are to having the ability to give thoughtful analysis…to bring in people from around the country, to work with partners from overseas, to say, ‘what’s the right approach on these issues?’ We’re not going to have that time.”

Larry Irving

Writing in Inside Story, Russell said it was shocking to see the Trump Administration was still pressing the US Supreme Court to abolish Obamacare, despite the pandemic’s huge toll and impact on the healthcare system.

She said Trump was seeking to de-legitimise the election process, as was predicted in a report ahead of the poll by Jonathon Swan of Axios.

“The delay in a clear result will test whether the American people can at least unite in exhibiting patience with the process, and whether the nation’s institutions are strong enough to withstand authoritarian efforts to override due process,” she wrote.

James Blackwell

Blackwell said he was less optimistic about a Biden victory than he had been going into the day, but had not lost faith Biden “can pull this off” with the outcome likely to become clear by the end of this week.

How the candidates called it

Twitter has blocked Trump’s tweet falsely claiming to have won the election.

Reaction from Australian health leaders

Alison Verhoeven, CEO of the Australian Healthcare and Hospitals Association

As many in Australia and across the world watch the results of the US election tonight, which looks set to be a nail-biting event with the outcome potentially not clear for some days, I am reminded of this time four years ago when I was in Washington with a group of AHHA members at a primary health leaders conference on the night of the 2016 election.

A day that started with optimism that the hard-fought Affordable Care Act would make healthcare more accessible to all Americans ended in despair and a sense of panic as health leaders came to grips with what for many was an unthinkable result.

We know more now than we did in 2016 about a Trump-led United States, much of it worse than could have been imagined.

Amongst many observers, there’s a strong sense that another four years of Trump leadership will have significant impacts far beyond the US borders. The rejection of science, the reckless approach to the COVID-19 pandemic, climate change denialism, racist policies towards immigrants and Black Americans, and provocative behaviours in international relations that compromise international security are just some of the issues which ought to concern us all.

Should Biden prevail, there are real fears of civil unrest; and longer-term, much will need to be done to rectify the damage that has been done particularly during the COVID-19 pandemic.

And for all of us observing the US election, lessons are to be learned in our own communities. Strong, respectful and positive leadership makes our communities safer and healthier. Divisive, disdainful leadership with disregard for robust, evidence-based policies and community wellbeing weakens us all.

Adjunct Professor Tarun Weeramanthri, President, Public Health Association of Australia

Eyes across the world have been on the US election today, but the results may not be known for days or weeks. Free and fair elections define democracies, and Australians respect that process here and in other countries.

Democracy is good for public health, as much as authoritarianism is bad.

Counting votes is not fraud, and a premature declaration of victory before all votes are counted is anti-democratic.

The election outcome will determine the position of the US over the next four years with respect to critical international and multilateral agreements, including the Paris Climate Agreement and engagement with key UN institutions, in particular the World Health Organization.

We sincerely hope that, whatever the election outcome, there is peace and unity, in the US and the world.

Dr Deborah Gleeson, Senior Lecturer in Public Health, La Trobe University

It’s not only the COVID-19 response in the United States that hangs in the balance while we await the outcome of the US election. How quickly the world as a whole can recover from the pandemic is also at stake.

Global access to one or more safe and effective COVID-19 vaccines will be vital to address the health and economic devastation caused by the pandemic. But delivering a vaccine to everyone in the world in a timely way is a massive task that requires global solidarity.

The World Health Organization, together other global health bodies, has set up a global coordination mechanism for purchasing and distributing COVID-19 vaccines, called COVAX.

Ninety-two low and middle-income countries are depending on wealthy countries donating enough funds to COVAX to fund a vaccines for 20 percent of their populations.

So far, the US has refused to participate in COVAX. Instead it has been the global leader in hoarding far more than its share of the global supply of vaccines through advance purchase agreements with pharmaceutical companies, even before clinical trials are completed.

The Trump Administration has also failed to support the COVID-19 Technology Access Pool, a more long-term mechanism for achieving equitable access by sharing knowledge, data and intellectual property.

And it has rejected a proposal by India and South Africa made at the World Trade Organization to waive intellectual property rights for COVID-19 products.

A Biden Administration seems more likely to cooperate on global initiatives, and Joe Biden has committed to share any COVID-19 vaccine developed in the US with the world at large. While it remains to be seen how things would play out, these are promising signs.

Fiona Armstrong, Climate and Health Alliance (CAHA)

We are all thinking of the US as the election campaign plays out.

The early results do not suggest a clear winner yet (at 7pm AEDT) which underscores the extraordinary circumstances the US finds itself in – amid a raging pandemic, and a media environment in which information and disinformation is indistinguishable for many people, decisions are fraught for individuals and policymakers alike.

The results appear to confirm that the US is riven with tribalism, and neither side in this contest are likely to concede easily or soon.

With many postal votes yet to be counted in key states such as Michigan, Wisconsin and Pennsylvania, it may be days or even weeks before there is a clear winner.

We hope Americans will be patient and calm during this period of uncertainty, and apply the lessons of so many around the world during the COVID-19 pandemic, that we all do better when we look out for others, and remember that democracy, whilst imperfect, remains the best system for choosing our political leaders.

Dr Becky Freeman, School of Public Health, University of Sydney

Global institutions, like the World Health Organization (WHO), require countries to look outward and recognise how interconnected we all are – but Trump is a leader who in my perspective wants to profit from other nations.

I guess the most pessimistic thing I see is that how a political leader handles the pandemic apparently has very little bearing on how people will vote. I would have thought just letting people get sick and die would have been political suicide – but at least half of Americans don’t care to hold their leader accountable, let alone demand basic levels of safety.

Voter suppression is a huge factor, until this is remedied there will be no fair and free election in the US. The social determinants of health must include the ability to freely participate in elections.

This shouldn’t even be a close race. I can’t pretend to understand a nation that claims to be the world’s greatest democracy but in the same breath suppresses voting and incites violence to seize power.

Professor Adrian Bauman, School of Public Health and Charles Perkins Centre, The University of Sydney

Main messages from an epidemiological perspective is why did the media trust the polls, bleat continuously that Biden had an 8-10 per cent lead, when polls are flawed, and should have learned that in 2016 (media serious negligence here, although it gave them stories … but not truth).

Main health messages:

  • US pandemic will worsen, unknown upper limit of COVID-19 cases if Trump returned; and a bigger than expected Trump result will increase community opposition to public health actions to contain the pandemic. On the other hand, if Biden gets in, maintaining social distancing, masks, hand sanitiser and lockdown (which is needed in some US communities) will be extremely difficult to make happen in US because the Trump supporters will be emboldened to protest. This will cause civic anger and violence if public health measures are imposed on them  [as we have done, mostly peacefully and with good effect, in Australia).
  • The truth, especially truth in science, and here relevant to COVID-19, will be devalued, truth will become a negotiable commodity, and the reality will be post modern — all truths are possible; this will have a flow-on effect to other issues, eg childhood immunisation, even conventional medical therapy –  so it’s a polarisation and dumbing down.
  • WHO will suffer if Trump gets in, no other country will take the place of US funding, and support to low income countries will flounder, leading to epidemic malaria, resurgence of Dengue, possibly smallpox, and other vaccine preventable diseases, possibly other infections worsened by warming and climate change – so health may worsen. But the issue with Biden is that the polarization in the US will cause the US to become more insular, and it will likely reduce global engagement under both scenarios, but WHO will suffer much more under a Trump Administration that claims completely falsely that WHO is under Chinese control etc etc ; at least Biden will try, but the closeness of this election in the US, if Biden wins, will reduce his capacity for global support and leadership. But Biden will resurrect the CDC, which is a good thing for global health even if the US is more inwards looking.
  • The variable truth approach will spread; its already in Poland, Hungary , Turkey – and it will spread elsewhere: the US as a role model for unscientific “unscience”, and populists determining “truth” that many followers will mistakenly believe.

So this is bad for human progress, for an evidence based society, and the response will increasingly be demonstrations in the streets and violence, worse in countries like the US with no gun control regulation.

Other reaction

Tweet by Sonam Phuntsho Wangdi (the Kingdom of Bhutan) – Chair of the Least Developed Countries Group at UN Climate Change negotiations

Read the article.

#CroakeyLIVE participants


Twitter analytics

Two hundred and sixty-five Twitter accounts participated in the #USVotesHealth Twitter discussions between 6 October and 4 November, sending 1,895 tweets and creating more than 21 million Twitter impressions, according to Symplur analytics. Read the Twitter transcript here.

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