“American Exceptionalism” has traditionally referred to America’s perceived unique strengths: the democratic principles underpinning the country’s governance, the value placed on liberty, the merit-based opportunities available to all. Recently, America has become exceptional in other ways. In March 2021, the U.S. was ranked 96th out of 102 countries globally in its public health response to COVID-19. Particular areas of weakness included a decrease in life expectancy, and a magnification of inequalities and abuses that have long been endured by communities of color.

American donors and institutions have traditionally engaged in global health by offering other countries scientific expertise and financial resources to support public health initiatives. Yet, the U.S. approach to global health has increasingly been criticized for embodying elements of neocolonialism and supremacy. As women leaders in global health, we recognize the urgency of approaching public health – both domestically and internationally – in new and different ways. Underpinning this are principles of decolonization and a push to reform foreign aid. In order to strengthen public health responses, we outline four areas that must be addressed moving forward.

The U.S. continues to grapple with a deep mistrust of science and the institutions charged with protecting health around the world. While no country or political administration is beyond criticism, the U.S. can learn from others who have tried to address this kind of public mistrust.  For example, Rwandans have shown a high level of confidence in the health system due to frequent, collaborative partnerships with local community leaders. In Northern Nigeria, politicians and public health professionals engaged religious leaders to become allies in promoting vaccination campaigns and preventing misinformation. In Pakistan, the recruitment and engagement of women to conduct door-to-door visits during vaccine campaigns improved direct access to individuals who are not easily reached by mass media campaigns. Many countries have used micro-planning and other analytic approaches to methodically assess community risk and strategies to ensure community health. Moreover, experiences around the world show that as communities see their concerns addressed by researchers and policymakers, they have greater confidence in science, which in turn, fosters a culture of public support for important public health initiatives.

The U.S. health system relies heavily on a decentralized network of hospitals and clinics, each with different administrative structures, resource allocation, and patient mixes. Fundamentally, the U.S “public health system” is largely separate from much of the rest of the healthcare delivery system, and increasingly lacks the funding, infrastructure and community engagement necessary to address complex health threats like COVID-19. In contrast, in countries like South Korea and Vietnam, the public health system allows efficient contact tracing and disease surveillance that is managed centrally, with one authority setting quality control standards and coordinating enforcement. During the pandemic, both countries balanced centralized quality control with deep community engagement to make sure communities understood the stakes and became partners in the COVID-19 response. As a result, South Korea was able to find asymptomatic spreaders and conduct faster, more comprehensive contact tracing. Similarly, in Vietnam, community partnership in social distancing and sanitation practices made it possible to maintain a fully open economy for months. Early in the pandemic, Taiwan’s epidemiology-trained Vice President moved quickly to screen travelers, isolate anyone showing symptoms, and gather data on asymptomatic cases. With fewer than 1,000 COVID-19 cases until recently, Taiwan’s approach has demonstrated the power of centralized, science-based leadership. Similarly, Rwanda was rigorous in its approach to testing and contact tracing by leveraging health workers early on in the pandemic. 

Historically, there are few comparisons to the current mass vaccination effort that is underway in the U.S. which aims to immunize almost the entire population in the middle of a deadly pandemic. The most recent analogies are the Polio Elimination campaign which started in the mid-1950s and the 1976 Swine Flu Vaccination Program. While the expedited development of the vaccine is a success story for the U.S, the roll-out of vaccinations has led to inequities in coverage, and failed to address the concerns of communities throughout the country. The lack of a public health infrastructure should have triggered the mobilization of a “whole of government approach” (used for foreign assistance programs like PEPFAR) for domestic mass vaccination. The agreement between the Federal Emergency Management Agency and Peace Corps to support Community Vaccination Centers across the U.S. was a good but late effort. In contrast, Singaporerecognized the challenges of mass vaccination early, and recruited some of its top military logistical and tactical talent. The result was a highly successful campaign that leveraged uniformed citizens to build trust in public health efforts and establish distribution protocols that allowed the government to get medical supplies where they were most needed.

The U.S. is in the midst of one of the most divisive periods in its history. The political and social landscapes are increasingly defined by conflict, polarization, and radicalization, enabled by social media algorithms that hold people’s attention by directing them to increasingly extreme perspectives. Nations like New Zealand have fared better during the pandemic, and one of the reasons cited is strong leadership by women. A recent study found that countries led by women suffered less mortality (by a factor of six) from COVID-19 than those led by men. Several analyses highlight the important role women leaders have played in building unity and responding effectively to the pandemic and identifypositive traits of these leaders, including integrity, empathy, clarity, and decisiveness. Notably, only 9% of the original U.S. White House Coronavirus Task Force were women, demonstrating a troubling lack of representation and gender-responsive governance. 

The pandemic has created an opportunity for the U.S. to do better by engaging the global community and learning from others who have outperformed us. Now that the U.S. has rejoined global health platforms like the World Health Organization and COVAX, it should openly engage in two-way learning exchanges with other countries to find and share the best expertise and solutions, no matter where they may have originated, so that everyone may collectively benefit. In this process, we must reject vaccine nationalism and, instead, take concrete steps to ensure vaccine equity around the world. America has long been a melting pot of global ideas; now, we must bring together the best of what is being learnedaround the world on an ongoing basis. By doing this, we will demonstrate how America can be exceptional again – but this time as a partner in learning from and collaborating with others, with a greater sense of humility. 

This article was written by the inaugural 2020 cohort of WomenLift Health including: Allison Phillips, MA, Bindiya Patel, MPA, Brittany Hume Charm, MBA, Callie Simon, MPH, Cheryl A.Moyer, MPH, PhD, Christine Ngaruiya, MD, MSc, DTM&H, Deepika Kandula, MPH, MBA, Ingrid T. Katz, MD, MHS, Iris Mwanza, PhD, Jennifer Goedken, MD, Kashmira Date, MD, MPH, Kate H. Rademacher, MHA, Megan Huchko, MD, MPH, Michelle S. Hsiang, MD MSc, Nandini Oomman, PhD, Nureyan Zunong, MPH, Sia Nowrojee, MSW, Skye Gilbert, MBA, Vivian Hsu, MBA. 

Photo by Luke Stackpoole on Unsplash.