Crises talk and the foreclosure of repair

The Trump’s administrations 2025 decision to withdraw from the World Health Organization (WHO) and cut 83% of its USAID-funded programming triggered a familiar response across the global health system, with commentators warning that global health has entered another crisis. This retrenchment coincides with similar, if less visible, funding cuts across Europe: Belgium (25%), the Netherlands (30%), France (37%), the UK (40%) [1,2]. Yet what is being narrated as a breakdown through these recent ‘Big Events’ has made visible the racialized political economy in which some populations remain systematically vulnerable to preventable death while others retain the power to define what this moment means and determine the terms of response and recovery.

For the global majority, this condition is not exceptional. Global health has perennially been characterized by a perpetual state of crisis. Communities across the Global South have faced outbreaks that never rise to the threshold of global alarms, chronic funding insecurity because donor priorities do not align with local needs, and intensifying health harms linked to climate change, debt and weak public health systems [3–6]. This was exceptionally visible throughout the COVID-19 pandemic. Millions of Black and brown people died while predominantly white, wealthy nations hoarded vaccines, defended patent monopolies and blocked efforts to expand manufacturing in the Global South [7,8]. Contra claims that this was a departure from the ordinary logic of global health, the better view is that this was an acute expression of a longer history in which colonial medicine treated racialized peoples as expendable subjects of experimentation while locating scientific authority and pharmaceutical control elsewhere. That same logic persists in outsourcing of clinical trials, the interpretation and enforcement of WTO intellectual property (IP) rules, and the continued restriction of local pharmaceutical production across Africa and other parts of the Global South [8–11].

We use the concept of the ‘crisis from of global health’ to make sense of this condition. Foreign aid became necessary only after colonialism and imperialism made it necessary. Global health remains embedded in that order. Some countries are made to carry heavier disease burdens, weaker health systems, more debt, less fiscal space, and less authority within the institutions that govern them, while others retain the power to define priorities and monopolize the control of resources and terms of repair. These inequalities are grounded in the material and epistemic organization of global health itself and through the wider racialized global political economy of which it is constitutive [12,13]. The crisis form names a pattern in which enduring structural instability is treated as normal, while acute disruptions are selectively framed as crises. Communities forced to survive funding shocks, epidemics, debt burdens, and institutional abandonment, rarely secure the time, resources and political space needed for repair. Thus, crisis talk organizes a politics of postponement in which structural redress is deferred in the name of urgency, resilience, and emergency response.

This essay takes reparatory global health as its political and conceptual standpoint. We begin with the recognition that present health inequalities were historically produced. Imperialism and coloniality, across racial slavery, colonialism, neo-colonialism and neo-liberal restructuring, have shaped the very conditions in which global health emerged and continues to operate. Debt, IP monopolies, ecological extraction and epistemic domination are the constitutive conditions of global health. Thinking about crises in global health is therefore misleading when it begins with the assumption that a fundamental legitimate system has failed to distribute care fairly. A more adequate starting point recognizes that harm has been built into its historical formation. From that perspective, reparatory global health asks what redress is owed when present inequalities are historically accumulated, institutionally produced, and politically maintained. It is orientated toward redress, transformation and non-recurrence. It asks not only how to compensate those who have been harmed, but how to dismantle and remake the arrangements that keep reproducing harm in new forms.

That starting point also changes how we read the present. For communities in the Global South and marginalized groups in the Global North, this terrain is familiar. Many have long built infrastructures of care, resistance and solidarity beyond western validation or leadership, and have not only endured abandonment but also sustained other ways of organizing health and life. Drawing from those struggles, from Alma-Ata to global coalitions and theories of reparative world-making [14,15], we argue for a horizon of global health grounded in mutuality, redistribution and epistemic plurality. The present moment should therefore be read less as a collapse of a previously stable order than as an opening to reconfigure the terms of global cooperation by centering those who have long been subjected to the foreign gaze [11].

A historical account of the crisis form of global health

The concept of the crisis form of global health becomes clearer when read historically. First, if we take seriously that the ‘global’ in global health inherits international (and world health due to the incorporation of world systems theory), then ‘global’ becomes an analytic for the specific historical relations constitutive of colonial medicine to our present world, not simply a descriptor for a ‘loosely unified set of institutions, discourses and practices,’ which go beyond the nation state as the primary object of analysis [16]. Second, given the form and content of global health, it ought to be appreciated that global health has been organized through a recurring pattern in which structural inequality is normalized, acute disruptions are rendered visible as Big Events or emergencies, and the response to those emergencies restores authority without disturbing the order that produced harm. Here, we distinguish between ‘enduring crisis’ and ‘heightened visibility’. Enduring crisis refers to the ordinary organization of the global health order, in which some populations live with weak health systems, debt burdens, fragile infrastructures, uneven exposure to disease, and little authority over the institutions that govern them. Heightened visibility refers to those moments when this underlying arrangement becomes harder to conceal, as in pandemics, aid shocks, or institutional withdrawals, to which the language of crisis is usually attached. The crisis form of global health asks us to begin with the former.

This historical pattern is inseparable from imperialism, colonialism, and racial capitalism. Few would disagree that international health emerged to protect European empires as opposed to a universal commitment to human flourishing [17]. Centering this history within a broader Global South retelling helps avoid dispossessing memory in ways that make global health look apolitical [18]. Colonizers developed health policies because disease threatened military occupation, labour productivity, administrative control, and the circulation of commodities and capital [17,19]. Malaria and yellow fever was important because they undermined the extraction of value from the tropics; cholera mattered because its spread triggered quarantines on shipping, interfering with trade and raised the cost of commercial exchange. The first International Sanitary Conference in 1855 emerged precisely from this problem, as Mediterranean states sought stricter quarantines (which Britain opposed) that would slow trade and increase costs [17]. Thus from the outset, international health was structured by a contradiction between disease control and accumulation. But the conventions did not resolve the contradiction; instead, they institutionalized it, and health became a way of managing circulation under imperialism [19].

The postwar period changed the grammar of global health but retained its logic. Creating WHO unified earlier regional health bodies and gave health a more universal institutional language, but this development was scaffolded by a Cold War struggle over world order [20]. The US and its allies supported multilateralism to stabilize a capitalist world in which newly independent states would not turn to the Soviet Union or embrace socialist development. Health aid and development policy were constitutive aspects of that strategy. Foreign aid expanded as a way of shaping political alignment and securing influence over the direction of state-building. Modernization theory gave this project an intellectual vocabulary, positing that all societies moved through universal stages of development and could be guided towards modernity through the right mix of capital, technology and institutions. Through this imaginary, colonizing states were framed as models of progress, obscuring the extractive relations that produced global inequality, and helped consolidate a technocratic politics in which health problems were solvable through targeted interventions while wider political economy remained intact.

Alma Ata briefly provided reprieve. Some newly independent states with their increasing majority and entry to the UN advocated health as a human right and for universal access to Primary Health Care, as part of a wider struggle against poverty and postcolonial dependency [21]. This movement culminated in the 1978 Alma-Ata Declaration on Primary Health Care; a landmark moment filled with optimism. Its rallying cry, “Health for All by the Year 2000,” proposed a shift away from narrowly focused, disease-specific programs toward inclusive, community-centered healthcare, linking health to broader postcolonial struggles against poverty and inequality [22]. But this vision was quickly sacrificed to neoliberal restructuring. Health systems were undermined by structural adjustment programs, and the comprehensive aims of Alma-Ata were abandoned in favor of more narrowly focused “selective primary care” [21]. These donor-friendly, vertical interventions were cheaper, more measurable, and easier to control. The WHO, under pressure from donors, scaled back its support for Alma-Ata, while its budget was increasingly reduced [23]. What was lost was a political understanding of health as crucial to sovereignty, redistribution and structural change.

The HIV/AIDS crisis in the 1980s and 1990s followed the same logic. Brandt argues that the crisis disrupted older, state-centered forms of international health, birthing global health and briefly opening space for rights language, activist intervention and demands for access to medicines [24,25]. New institutions like the Global Fund and PEPFAR emerged, channeling unprecedented funding to the epidemic, treatment expanded, and civil society gained visibility within global governance. But these gains did not transfer power in any fundamental sense. Donor states and philanthropic actors retained decision-making authority while recipient states remained subject to conditionality and external financing priorities [26]. Health systems in the Global South became increasingly oriented around AIDS at the expense of broader health needs [27]. AIDS responses were hailed as global solidarity but relations of care remained donor-driven, and crisis expanded control instead of dismantling it.

SARS, Ebola, and COVID-19 each repeated this structure with different emphases. SARS 2003 revived anxieties about global vulnerability and led to renewed surveillance capacities, through updates to the International Health Regulations (IHR), but enthusiasm for change faded once the threat receded [28]. The 2014–2016 Ebola crisis in West Africa exposed the violence of underfunded health systems in West Africa and made colonial afterlives difficult to ignore. Again, calls for reform surged, including proposals to strengthen WHO’s emergency response and to support the work of the Africa Centers for Disease Control [29]. As the crisis waned, momentum faded, and many reforms remained incomplete. COVID-19 has been the most dramatic case of all [30]. Predominantly white, wealthy countries hoarded vaccines, resisted patent waivers, and prioritized national recovery, while Black and brown people in the Global South were left to plead, wait and bury their dead [31]. Not even the vaccine inequity that animated the pandemic, and exposed structural problems, such as limited vaccine manufacturing in the Global South, weak health financing, and the legacy of extractive aid, could turn the tide [32].

Discursive responses to U.S. Retrenchment

Like previous moments of crises, the 2025 US withdrawal from the WHO and suspension of most of its foreign aid funding, was narrated not as an opportunity to rethink the relations of global health, but as a moment to restore its hegemonic order. In the wave of commentaries catalyzed across publication houses, following the announcement from Washington D.C., commentators overwhelmingly treated the event as a geopolitical rupture—an abdication of leadership, a threat to multilateralism, and a moment requiring urgent institutional repair. But beneath their tonal variation, they held a shared assumption: that U.S., and Western leadership more broadly, is both virtuous and strategically indispensable. An inductive thematic analysis reveals five dominant narrative frames: leadership vacuum, geopolitical rivalry, EU stewardship, African self-reliance, and decentralized multilateralism (Table 1). While these framings gesture toward different futures, they largely operate within the lens of continuity.

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Table 1. Discursive Framings of the 2025 U.S. Withdrawal from the WHO and Global Health Aid Cuts.

https://doi.org/10.1371/journal.pgph.0006473.t001

We found these frames from a targeted review of 23 English-language texts published between 1 January and 15 April 2025 that sought to understand how scholars, experts, and other stakeholders, understood the governance challenges aid cuts and WHO withdrawal presented and potential solutions. The initial step was a PubMed and Scopus search, which generated 728 entries; only three met our criteria after abstract screening. We located additional sources through targeted Google queries, resulting in a final total set of 23 publications. We have attached an annex with full inclusion and exclusion criteria.

Leadership

A dominant frame, particularly among Global North commentators, casts the U.S. exit from the WHO as creating a perilous “leadership” or “political power vacuum” [33,34]. The U.S. exist was described as creating systemic instability, threatening WHO reform, and weakening global health security [33–37]. The WHO itself expressed deep regret, emphasizing that U.S. participation had helped catalyze the “largest set of [WHO] reforms in its history,” and warning that its departure would weaken global efforts to detect and respond to health emergencies [38]. References to a “void” carried the affective weight of crisis, implying not merely absence but imminent danger [39]. This framing positioned the U.S. not as one actor among many, but as the linchpin of global health governance. Its absence rendered as an existential threat. In doing so, these narratives re-centered the U.S. as necessary to the field’s coherence, effectively foreclosing any serious reckoning with its past or present role in undermining global health, for example, through policies like the Global Gag Rule, which restricts funding for NGOs that even mention reproductive justice [40]. Though formally limited to NGOs, the policy has caused widespread disruptions: clinics have closed, access to care has declined, and advocacy has been chilled [40–42].

Geopolitics

Closely linked to this was the geopolitical rivalry frame, in which China and Russia’s growing influence was cast as a threat to Western values [37,43,44]. Commentators expressed concern that Beijing would use the vacuum to export authoritarian models, bypass multilateralism, and entrench undemocratic norms [37,39,43,45]. Others expressed concerns that civil society would be left exposed, emboldening “rivals” like China and Russia to deepen their influence in fragile states [46]. Yet these anxieties rarely interrogated the ideological content of Western values or U.S. leadership itself. Instead, they reinscribed Cold War binaries, treating the Global South not as an active subject but as terrain to be contested. In this frame, global health becomes the battleground for liberal versus illiberal governance models.

European stewardship

A third narrative, foregrounding European stewardship, cast the EU as the natural heir to U.S. leadership. Commentators urged the EU to step up morally, financially, and institutionally, positioning it as the guarantor of multilateral stability [33,47–49]. This framing rested on the assumption that the preservation of global health depends on continuous leadership from the Global North. Some interventions presented this as an opportunity for the EU to project soft power, protect its economic interests, and secure geopolitical influence [50–52]. Others emphasized humanitarian obligations [53]. Yet both tendencies instrumentalized Global South health needs within a European strategic calculus.

African sovereignty

In contrast, African commentators and regional actors offered a partial reframing. Here, the withdrawal was not simply a loss, but a provocation—a moment to confront long-standing dependencies. Some treated the crisis as a wake-up call, urging investment in local production, research autonomy, and regional integration [38,44,54]. This sovereignty frame presented aid as a neocolonial constraint and called for a break with donor-driven development [55,56]. Yet even these interventions were uneven. In some instances, self-reliance was reframed through a managerial lens: through efficiency, fiscal discipline, and institutional reform [57–60]. Others, more radically, gestured toward Pan-African political traditions and structural reorientation, asserting that “true development cannot be outsourced” [61]. Still, across much of the discourse, critiques of aid were decoupled from critiques of racial capitalism, limiting their transformative potential.

Decentralized multilateralism

A final frame, decentralized multilateralism, proposed a shift away from hegemonic leadership altogether. Rather than replacing the U.S. with another dominant actor, some commentators advocated for shared governance structures that distribute authority more equitably across regions [39,62]. This included calls to empower institutions like the Africa CDC, diversify funding streams, and democratize decision-making within the WHO [33]. On the surface, this appears to challenge the existing order. But closer scrutiny reveals the limits of this vision. Proposals often lacked clarity on how power would be redistributed or how entrenched hierarchies would be dismantled. The language of decentralization remained technocratic, focused on efficiency and resilience, rather than structural transformation.

What unites these discursive frames is that none treats the crisis as produced by global health’s own governing relations. Rupture rhetoric is pervasive, but its political content is thin. Leadership is assumed; sovereignty is detached from redress; multilateralism is reduced to coordination rather than solidarity [33,34,37,39,62,64]. This is clearest in the silence around decoloniality. Despite years of debate on “decolonizing global health,” none of the texts engaged its substantive demands [65]. Even appeals to self-reliance remain severed from the histories of colonial subjugation and racialized dependency that made such dependency durable [53,54]. The result is a discourse that treats the withdrawal as a problem of institutional repair, not as an opening to confront the extractive relations of the system. In that discourse, the Global South appears mainly as the site where crisis lands, not as an author of what global health should become [33,38,63,66].

The necessity of reparatory action in global health

Reparatory global health remains difficult for mainstream global health to imagine because the field has been shaped within a narrow political and epistemic horizon. It still privileges Euro-American assumptions about expertise and technical reason [67]. It treats inequality as a problem to be measured and mitigated without addressing the historical and structural relations that produced inequality [68]. The same narrowing appears institutionally. Funding streams, journals, policy, and multilateral institutions reward proposals that promise resilience and reform but are far less hospitable to arguments about restitution, debt cancellation, monopoly-breaking, or redistributing authority. Crisis discourse intensifies this problem because it creates urgency and then channels that urgency into rescue missions aimed at restoring governability and institutional continuity. The result is a field that hyper focuses on responding to acute events but not how to think about structural change. Reparatory global health, then, appears difficult to imagine not because it lacks intellectual substance, but because it requires a different way of seeing the problem: it requires us to treat colonialism, slavery, racial capitalism as constitutive formations of the present, and not historical episodes.

Reparations literature has already begun to do that work naming slavery, underdevelopment, inequality and climate vulnerability as part of a continuous historical present where unequal contribution to harm, unequal exposure, diminished adaptive capacity, and unjust enrichment are key considerations for redress [4–6,69,70]. Reparatory global health demands a break with the habits of thought that have made structural repair unintelligible. Contemporary African scholarship is helpful here because it links colonialism, economic inequality, and the need for structural justice in ways that help reproduce harm.

Reparatory global health rejects the premise that inequality can be managed through inclusion. The problem is not the underrepresentation of the Global South in existing institutions, but the very form that renders inclusion a substitute for power. Reform initiatives often seek to diversify actors without transforming the terms of participation. Yet when the field’s foundations are built on histories of dispossession, representation without redress becomes a mode of containment. Reparations, in this context, are not about settlement or apology. They are about structural realignment—redistributing authority over health priorities, research agendas, and funding flows [22,71–75]. Reparations must reconfigure the future, not only reconcile with the past on unjust terms [15].

Across the Global South, communities have long built infrastructures of health sovereignty, mutual aid, and collective living that have often flourished outside donor-led paradigms. Marginalized communities the world over have responded to systemic neglect not only with resilience but with innovation: from grassroots care networks to pan-African public health platforms, and indigenous knowledge systems to South-South cooperation. These are not peripheral stories; they are central to the making of global health. To draw from them is not to romanticize, but to recognize that alternatives already exist, and have for a long time. The question is not whether transformation is possible, but whether we are willing to shift our gaze and ground our imaginaries in these other inheritances. In place of crisis-as-loss, we offer crisis-as-opening: a moment not only to name what has failed, but to reclaim what has endured.

Social movements

Reparatory global health is not a technical blueprint––it is a political struggle of which social movements is a central part. It is a paradigm shift: from managing populations to sustaining life, from crisis management to collective transformation [14,15]. Its horizon is not just dismantling systems of harm, but affirming life worlds grounded in solidarity and care. History provides both visions for imagining a world, otherwise, but it also cautions. Movements like Brazil’s Sanitary Reform, demands for a Global Social Protection Fund, the Black Panther Party’s community clinics, and Cuba’s medical brigades, have long modelled health as a site of resistance and repair [22,71–73,75,76]. These were not mere technical or policy interventions; they were confrontations with imperial power and assertions of health as a right bound to sovereignty and dignity, and as a key aspect of living in the world as a collective. Alma-Ata’s call for “Health for All” embodied this ethos before being gutted by structural adjustment and donor capture. Still, its emancipatory vision remains––a reminder that alternatives have always existed, displaced by those now offering reform. Reparatory global health takes its cues from these struggles. It insists that health is inseparable from land, labour, and liberation. And that justice cannot be integrated into global health as it stands, but the force that reconstitutes it.

Legal forms

This requires confronting how global health has been shaped by legal forms. Global trade and intellectual property rules have been exposed as technologies of containment. From the TRIPS Agreement to donor-driven conditionalities, legal forms have protected property and external authority instead of guaranteeing access to essential medicines and strong health systems [77]. The COVID-19 vaccine apartheid underscored the need for a framework that enables poorer nations to produce essential medical goods for their populations. Acknowledging the ability of nations to manufacture, distribute, and innovate without relying on monopolies or external benevolence is an imperative. All countries should contribute, with wealthier nations bearing a larger share as part of their reparative responsibility, having extracted resources from the Global South, benefited, and failed to compensate. A reparative orientation would reframe law as a site of struggle, not stability. Crucially, this is not a call for more law but for law otherwise––attuned to historical theft and oriented toward collective flourishing.

Epistemology

Equally critical is the terrain of epistemology. Who produces knowledge, whose expertise is validated, and which ontologies shape health interventions are all central to reparatory politics. Despite rhetorical commitments to “context” or “local ownership,” global health remains dominated by Euro-American biomedicine and evidence paradigms [78]. Reparatory global health insists on epistemic justice, not as a gesture of diversity, but as a challenge to colonial rationalities. It foregrounds Indigenous knowledge systems, relational models of care, and non-Western practices not as supplements to existing paradigms but as coequal foundations [16]. Sylvia Wynter’s call to reimagine the human beyond the colonial matrix becomes instructive here: the project is not to diversify the existing order, but to deconstruct it [79]. To claim reparations is to insist that knowledge itself has been racialized, and that healing must begin by unmaking its hierarchies. Otherwise, that is not truly “global health”.

Institutional forms

This reconstitution must also engage with the form of global health institutions. The WHO, long constrained by donor earmarking and geopolitical pressure, operates within a relational form that privileges wealth over need, and vertical interventions over holistic care. A reparative approach would not merely increase funding or representation but would transform the institutional logic altogether. It would require binding obligations for equity, mechanisms for downward accountability, and the redistribution of agenda-setting power. Such a shift cannot be achieved through soft law or normative persuasion alone. It demands political struggle: to democratize governance, to rupture donor conditionalities, and to repurpose the system around justice rather than stability. Without institutional transformation, even the most progressive discourses will be absorbed and neutralized by the very relations they seek to challenge.

One health

Reparatory global health must foreground ecological justice—not as an environmental add-on, but as foundational to collective health. The rise of One Health discourse, linking human, animal, and environmental well-being, offers a conceptual opening [80,81]. Yet in practice, it is often deployed in technocratic, surveillance-based terms, tracking zoonoses, anticipating outbreaks, protecting borders. It has been effectively co-opted from its long enduring roots in Indigenous knowledge systems across the world. A reparative lens would recast One Health as a political project: one that recognizes climate debt, land dispossession, and the role of racial capitalism in producing health crises. It would invest in agroecology, community-controlled food systems, and climate-resilient care infrastructure. Crucially, it would take seriously Indigenous ecological knowledge, not as data to be mined, but as forms of relations that unsettle Western ontologies.

Conclusion

Our proposals are not final answers. What we offer is an invitation to rethink and reimagine how we live as a collective. What links them is a shared commitment to actual transformation, rather than applying superficial fixes to a system built on inequality. Strengthening regional leadership challenges the legacy of external control and paternalism. Ensuring rights to manufacture and access essential medicines targets the structural economic injustices that keep care out of reach for millions. And reimagining health through an ecological and reparative lens expands our vision to include long-ignored dimensions of justice: social, environmental, and epistemic.

None of this will be easy. These ideas confront entrenched colonial relations of power built on and sustained by extraction, accumulation, and dispossession, and will be resisted by those who profit from the status quo. But if global health is—as many now say—burning, then tinkering at the margins will not put out the fire. We need a different approach entirely. Reparatory work offers that shift towards abolition: it asks us to stop patching up a crumbling system and start addressing why it is failing in the first place. It invites us to rebuild a new, using materials that are just, inclusive, and designed to prevent future collapse. In moments of crisis, it is easy to think justice can wait. But it is precisely now, amid the wreckage, that we must prioritize it. Reparative justice is not a distraction; it is the extinguisher, and the blueprint, for something better. Only by rooting global health in solidarity, repair, and shared responsibility can we transform this endless cycle of crisis into a chance for collective well-being. This is the path to a future where global health is not shaped by domination or charity, but by mutual care, equity, and the collective pursuit of well-being for all.