Disappearing global health leadership

When the United States decides to be a global health leader, it can lead like no other. With CDC and USAID already core partners in WHO-led initiatives such as eradicating smallpox and polio, as well as childhood immunization, U.S. global health engagement rose to a new level in 2003 with the launch of the President’s Emergency Plan for AIDS Relief (PEPFAR), the largest commitment by any nation to address a single disease. PEPFAR shows what is possible through compassionate, cost-effective, accountable, and transparent global health assistance.

U.S. health and humanitarian funding has been lifesaving. American contributions accounted for nearly half of all funding for humanitarian emergencies in 2024 – five times as much as the next largest funder, the European Commission [5]. The U.S. has provided one-third of Global Fund financing [6]. In the closing funding cycle, 2021–2025, the US provided 24% of the direct contributions to Gavi, the Vaccine Alliance [7]. All told, the US has been spending over $12 billion annually on global health, more than five times the contributions of the next largest funder, Germany [8].

Along with funding, the United States shares technical scientific expertise, above all through CDC, including emergency outbreak response, training, data collection, disease surveillance, and epidemiology. Last year, 1,700 CDC staff were based in more than 60 countries to surveil and respond to more than 400 diseases and health conditions [9]. The US launched the Global Health Security Agenda in 2014—now consisting of more than 70 partners that evaluate and strengthen health systems [10]. The Fogarty International Center at the National Institutes of Health (NIH) has trained 8,500 scientists from low- and middle-income countries (LMICs) [11]. And the Food and Drug Administration’s determination that a medicine is safe and effective is widely recognized as a gold standard, often used by LMICs in their own drug approval processes.

Withdrawing from the World Health Organization

The U.S. has been WHO’s largest donor, contributing approximately 15% of its total budget [12]. U.S. contributions have funded some 25% of WHO’s Health Emergency Programme’s core work and 20% of its emergency response [13]. Due primarily to the halt in U.S. funding, WHO implemented a hiring freeze and major budget cuts at its Executive Board meeting in January 2025 [14]. Two months later, WHO’s Director-General announced a cut of over $1 billion from its 2026–27 budget, amounting to a 21% reduction of its original $5.3 billion core budget to only $4.2 billion [15]. That level of funding is wholly incommensurate with WHO’s global health mandate.

WHO’s budget cuts are leading to a dramatic organizational restructuring, including headquarters downsizing. The agency’s 10 major program divisions will be cut to only three overarching program areas: health promotion, disease prevention and control; health systems; and health emergency preparedness and response. The number of departments will be nearly halved, with health and migration among those eliminated. Health and human rights will be downgraded. Large-scale job losses are looming, expected to exceed 40% of staff, particularly at WHO’s Geneva headquarters [16].

Shunning WHO treaties

Even after the U.S. withdrawal from WHO takes effect on January 22, 2026, the United States will technically remain a state party to the International Health Regulations (IHR), which is a distinct legally binding international agreement, also open to non-WHO member states. However, President Trump’s WHO withdrawal executive order also stated the US would not adopt or enforce the regulations’ amendments adopted in June 2024 in the wake of the pandemic and meant to facilitate equitable access to health products in a health emergency [1]. On July 18^th, the U.S. officially withdrew from the IHR amendments in a joint statement by Health and Human Services Secretary Robert F. Kennedy, Jr. and Secretary Rubio [17]. This marks a sharp departure from the Biden administration, which was a key driver of the amendments. The president also withdrew from negotiating the WHO Pandemic Agreement, adopted by the 2025 World Health Assembly, discussed below.

Dismantling USAID

In only a matter of weeks, and in defiance of the law, the Trump administration took USAID, the world’s largest aid agency [18], and turned it into an organization that had all but ceased to function. Secretary Rubio’s January 24 stop-work order began the rapid unravelling of USAID, with thousands of contractors laid off within a week [19]. By that point, the USAID website had been taken offline, and USAID employees were barred from entering its headquarters. In the coming weeks, the administration fired or placed on administrative leave most USAID employees [20,21].

On March 28, the Trump administration put the final nail in the coffin of USAID, ending the agency in all but name. Before President Trump entered office, USAID employed about 10,000 people. Now, the administration said, the agency would be reduced to 15 legally required positions [22].

In little over two months, America’s storied foreign aid agency was purged and effectively eliminated. On July 1, the administration officially closed the agency, folding remaining employees and programs into the State Department.

Judicial pushback and acquiescence

On February 13, a district court judge issued a temporary restraining order requiring the government to resume foreign assistance funding. Yet, the Trump administration repeatedly refused to comply, and later that month terminated most USAID grants and contracts, asserting falsely that the terminations were the result of an individualized review of all USAID awards. The administration also asked the Supreme Court to block the judge’s order to pay grantees and contractors for work already performed. The Court, in a 5–4 ruling on March 5, directed the lower court to clarify the government’s obligations [23].

Complying with the Supreme Court’s ruling, the district court ordered the administration to pay for work already performed. It refused to block the mass termination of grants and contracts, but did require the government to obligate all appropriated foreign aid funding, an order the administration appealed [24,25].

Meanwhile, the administration took another route to avoid spending appropriated funds – through Congress. Under the Impoundment Control Act of 1974, the administration may rescind funds – refuse to spend money Congress already appropriated – if the president makes a formal request and both the House and the Senate approve within 45 days. And this is just what happened. In a special message to Congress in June, Trump proposed rescinding $8.3 billion in foreign assistance funds [26]. The following month, Congress largely acquiesced. The Rescissions Act of 2025 rescinded approximately $7.9 billion in funding for foreign aid (along with $1.1 billion for public media). A significant portion of the rescinded funds were directly related to health, including funding for global health programs, humanitarian assistance, disaster response, climate change, poverty alleviation, WHO, and UN agencies including UNICEF and the UN Development Programme [26].

Meanwhile, as litigation continued in both the district and appellate courts, the administration informed Congress at the end of August of its intent to rescind another $4 billion in foreign assistance. With fewer than 45 days before the September 30 deadline for obligating the funds, the administration would in effect run out the clock. Even if Congress did not approve, the funds would expire and no longer be available for spending [27]. On September 26, a bitterly divided Supreme Court allowed the Trump administration to rescind the $4 billion in foreign aid funding [28].

As complex litigation proceeds in the U.S., a pattern is emerging. Lower court judges are pushing back but a Republican-controlled Congress is either remaining silent or affirmatively ratifying Trump’s actions, while a super-conservative Supreme Court majority is acquiescing to the administration’s end-around the Constitution. Shattered lives will be the result.

A new global health strategy

The America First Global Health Strategy discussed above will pivot away from supporting multilateral organizations and NGOs. Instead, the United States will sign bilateral agreements with governments, with a focus on commodities and frontline health workers. While HIV programs will continue in Africa, the plan shifts U.S. focus to the Western Pacific and the Americas.

Central to the plan is transitioning responsibility for health programs to partner governments, enabling the United States to reduce funding, aiming to end bilateral assistance to a majority of U.S.-supported countries in the next several years. In the short-term, partner governments will need to meet performance benchmarks to keep U.S. foreign assistance flowing. With the aim of preventing new and emerging infectious diseases from reaching the United States, surveillance and other pandemic preparedness and response activities remain a focus [4,29].

Endangering key U.S. global health programs

Along with the devastation of foreign assistance, two key programs raise particular concerns: PEPFAR, a keystone of the global AIDS response, and sexual and reproductive health. A third area of particular concern, like sexual and reproductive health targeted by the administration, are programs supporting the health and rights of LGBTQ+ and other marginalized populations.

Irreparable harms

It would be comforting to think all this damage can be undone under a new U.S. president in 2029. Sadly, the damage will be enduring and often irreversible. Programs discontinued will struggle to restart, career scientists and humanitarians laid off cannot easily be replaced, and organizations that lose funding may be forced to close forever. Trust earned over decades, both with patients and with partner organizations and governments, has been shattered, and cannot easily be repaired. Ultimately, the harm will be calculated in a fatality count that will very likely rise into hundreds of thousands, at least, and the millions if the programs are not restored. It is important to reflect on the sheer scale of this American carnage.

Among the most consequential cuts will be the end of U.S. funding to Gavi, the Vaccine Alliance. This alone stands to cost 1.2 million children their lives [23]. The cuts could lead to 18 million new malaria infections a year [20]. One funding cut will leave over 100,000 people in South Sudan without quality health and nutrition, while another cut means that more than 400,000 people in Burkina Faso will lose access to clean water and child protection [48]. USAID’s storied Famine Early Warning Systems Network has ceased operating [49]. And this is all alongside children who will not be educated, people with disabilities who no longer receive services, democracy and human rights advocates who lose vital support, and more.

How deep these harms will be, how many deaths will result, depends on what happens next. In a worst-case scenario, if the deeply diminished U.S. foreign assistance programs following the mass termination of grants and contracts defines U.S. foreign assistance for the rest of this administration, 14 million people whose lives would have been saved without these cuts will instead die through 2030, including 4.5 million children under five, accordingly to one analysis [50]. Trump’s FY2026 budget request proposed cutting foreign assistance in half – a $30 billion reduction – including a 61% decrease in humanitarian assistance and 62% cut in global health funding – as well as an additional $20 billion in rescissions [51]. Congress often goes its own way with the budget, effectively ignoring the major cuts to foreign assistance Trump proposed in his first term. Will the traditional bipartisan support for these programs re-emerge, or does Congress’s approval of almost all of Trump’s proposed rescissions indicate a new reality?

Looking longer term, a new president in 2029 could reverse some of Trump’s actions, but others will take far longer to rectify. A new president could return to the United States to WHO. Since Trump unilaterally withdrew from the organization, without Congress’s approval and without paying current dues to the WHO, a condition Congress had set for WHO withdrawal [52], a new president should be able to simply declare Trump’s withdrawal null and void. A new president could also affirm U.S. acceptance of the IHR amendments and sign the Pandemic Agreement.

The destruction of U.S. foreign aid infrastructure will be much more difficult, and take longer, to undo. Health and other specialized staff will be hard to replace. Relationships built over decades – with governments, NGOs, and especially communities – once broken, are difficult to repair. A decision would be required whether to reconstitute USAID or accept its illegal closing as a fait accompli.

All this will come in a changed foreign assistance and development landscape. A new, lower norm may have been established for U.S. foreign assistance funding. A new administration and Congress would need to decide whether there are elements of the America First Global Health Strategy to retain, what former elements of U.S. health assistance to restore – like partnerships with NGOs and an increased focus on Africa – and what new approaches to establish. Reduced foreign assistance will have further, still unknown implications linked to the success of efforts to increase domestic health funding and capacities, and bolster regional organizations like the Africa CDC.

Of course, the most significant impacts of the administration’s actions on international health assistance and humanitarian assistance are beyond repair: the millions of people who will lose their loved ones will never get them back.

Globally distributed manufacturing

COVID-19 vividly demonstrated the dangers of overly relying on high-income governments to donate and fund lifesaving vaccines and treatments. The world needs to move from a model of philanthropy to one of self-reliance. African countries, for example, are now embracing the idea of “health sovereignty,” which builds domestic and regional health system capacities. To ensure ample and affordable supplies of medical countermeasures, shared more equitably, we must diversify manufacturing capacities. Put another way, rather than waiting for charitable donations (which come too little and too late), LMICs seek to develop their own medical products. That could be a win-win: it would make historically neglected regions more self-reliant, while avoiding global supply shortages of medical products, helping everyone.

In an important step, WHO’s mRNA Technology Transfer Programme is working with at least 15 partners in Africa, Asia, and Latin America to become mRNA technology production sites, with the aim of sustainable mRNA technology production capacity across LMIC regions [57]. Much more will be needed, though, especially in Africa. There, most countries import 70% or more of their medicines [58], 90% or more of their medical devices [59], and a staggering 99% of vaccines [59]. Hardly any active pharmaceutical ingredients are produced in Africa. As of 2022, the African continent had 649 pharmaceutical manufacturing plants, whereas in 2019, China and India (broadly similar in population) had 5,000 and 10,500 such plants, respectively [59].

Last year, WHO’s regional office in Africa (WHO AFRO) adopted a framework to increase local pharmaceutical manufacturing, with targets of local production achieving 55% of market share by 2035, including at least 50% for vaccines [59,60]. The Africa CDC is also expanding its capacities and partnering with WHO AFRO. All this will require training scientists and health professionals, strengthening regulatory authorities, and technology transfer partnerships [59]. It will also require significant funding, estimated at $11 billion by 2030 for local pharmaceutical companies, along with $100 billion in infrastructure investments [61].

Countries that can contribute must contribute

Traditional global health donors are unlikely to compensate for U.S. cuts to global health and humanitarian assistance, as they are making their own cuts. Most dramatically, the United Kingdom, which in 2020 announced it was cutting development assistance from 0.7% to 0.5% GNI [62], now plans a further reduction to 0.3% GNI to enable increased defense spending [63].

In response to the war in Ukraine, the European Union will exempt increases in defense spending from its 3.0% GNI debt ceiling [64]. The EU could do the same for development assistance, with its life and death implications. Wealthy countries that provide a small percentage of GNI to development assistance should step up—for example, in 2024, Australia and South Korea invested 0.19% and 0.21% GNI, respectively, to development assistance. The average OECD Development Assistance Committee member contribution was 0.33% [65]. The wealthy Gulf states should also increase their development assistance to meet the OECD target of 0.7% [66].

China’s development assistance amounts to less than 0.05% GNI (0.03% at the lower end) [67]. Yet China has demonstrated capacity to generate enormous resources, such as for defense and economic stimulus. Even reaching 0.20% GNI would inject about an additional $25 billion in development assistance. New funding alone, however, is not enough to ensure impact. China and other donors without established, effective bilateral health agencies with a proven track record should direct much of the global health portion of their foreign assistance to global health institutions that do have a proven track record, including WHO, the Global Fund, and Gavi.

While increased contributions would create more resilient health financing, it is just as important for LMICs to increase domestic health investments. In the Abuja Declaration in 2001, African governments pledged to spend at least 15% of their national budgets on the health sector; yet only two countries are doing so [68].

High-income countries must offer debt relief

Governments that have saddled lower-income countries with crippling debt should embark on an ambitious program of debt relief. In 2023, the United Nations reported that countries whose populations today comprise 3.3 billion people spent more on servicing their debts than either health or education [69]. LMICs collectively spend 3.7% of their GNI servicing their debts [70]. Put another way, LMICs spend twice their official development assistance on debt payments [71,72].

In November 2020, the G20 launched its Common Framework for Debt Treatments, which was wisely designed to include all creditors – multilateral institutions and high-income countries, but also China and private creditors – but has been off to a languid start. Four years after its launch, only four of 73 eligible countries had begun the process; none had completed it [73]. Reducing nations’ debt, and thus debt service payments, will free up funds to invest in health, buffering against global shocks.

Local capacities

Far too much of traditional foreign assistance is funnelled through large international NGOs, rather than going directly to the people. Local organizations need the capacities to stand on their own regardless of the global landscape. Development partners should accelerate localization – directly funding local NGOs, as well as increasing local actors’ power in funding-related decision-making. Strategies would include funders easing reporting requirements, increasing outreach to local organizations, welcoming funding applications in local languages [74], and increasing funding for local capacity development. Pooled funding could channel health and humanitarian funding to local organizations [75]. Another benefit: local salaries mean that significantly more may be possible for equivalent sums, enabling remarkable impact at low cost.

WHO resilience and reforms

In this tumultuous era, strong WHO leadership is crucial. Yet the agency is chronically underfunded and could solidify the full trust and support of its members with targeted reforms to shore up institutional accountability and transparency. A first step would be to accelerate the multi-budget cycle increase in assessed contributions as a proportion of WHO’s budget [76]. In 2022–23, member states paid 22% of the organization’s base budget through assessed contributions, a proportion currently slated to increase to 50% of the 2022–23 base budget by the 2030–31 biennium. WHO should instead reach the 50% level with its 2028–29 budget, with further increases to follow. The current disruptions in core WHO operations cannot wait to be repaired until 2030. Furthermore, in the 2030–31 budget cycle and going forward, assessed contributions should be based on that biennium’s budget, rather than continue to harken back to a presumably smaller 2022–23 budget.

To regain public confidence, WHO should also improve transparency, financial oversight, and accountability. The recent WHO staff vote of no confidence in leadership was a call for good governance [77]. Among many areas for reform, WHO could create an independent inspector-general with authority to identify and investigate inefficiencies, ensure financial stewardship, and monitor and redress undue state influence and state noncompliance with the IHR.

Global health diplomacy and the Pandemic Agreement

WHO made a powerful statement of resilience by ratifying the Pandemic Agreement at the May 2025 World Health Assembly. Indeed, the U.S. withdrawal from negotiations opened opportunities to achieve consensus on more equitable approaches that the U.S. had opposed, such as on technology transfer and access to pandemic products. And adopting the Pandemic Agreement has enormous symbolic value, signalling an imperative to forge normative and diplomatic consensus at a time of shattered international cooperation. Member states could make a still more powerful statement by rapidly negotiating a robust Pathogen Access and Benefits Sharing (PABS) system in an Annex to the treaty in 2026. The 2025 World Health Assembly charged an Intergovernmental Working Group with negotiating a PABS system. It is essential that the working group succeed because the full treaty cannot be opened for signature until the PABS system is adopted.

The PABS annex, moreover, should be adopted in an historic World Health Assembly Special Session hosted in the Global South. This meeting in the Global South should not be a one-off event, but the beginning of a new practice of holding World Health Assembly and Executive Board sessions outside Geneva, especially in the Global South. Besides its symbolic importance, this could enhance public understanding of and support for WHO.