The United States has been an undoubted leader in global health over the past 80 years — in scientific innovation, financial assistance, and global governance. Yet the second Trump administration has shaken the foundations of US global health leadership. Sweeping policy shifts have threatened the world while disrupting long-standing US engagement across a wide range of global health challenges. Reviewing the first year of the second Trump administration, this column examines the retreat of US leadership, authority, and financing in global health; analyzes the impacts of US attacks on public health science, foreign health assistance, and global health governance; and reflects on how the world is responding to declining US leadership, with a mix of despair and some hope.
Longstanding US Global Health Leadership
The United States has played a defining role in shaping the global health architecture since the birth of the United Nations (UN) at the end of World War II. A central contributor in establishing the World Health Organization (WHO), the United States hosted the International Health Conference that drafted and adopted the WHO Constitution, holding preeminent influence over WHO’s programming in its early years.Reference Hilleboe 1 Under WHO and beyond, the United States became uniquely influential to global health advancements.
US foreign health assistance became a cornerstone of American soft power through its efforts to prevent disease and promote health throughout the world. The establishment of the United States Agency for International Development (USAID) in 1961 galvanized foreign assistance through bilateral agreements, and facilitated technical and economic support for health in low- and middle-income countries. 2 USAID’s work complemented the growing influence of US public health institutions, including the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC), which together helped to consolidate US leadership at the forefront of global health.
By the early 2000s, global health had become an explicit objective of US foreign policy.Reference Kickbusch 3 The United States helped to establish groundbreaking new global health institutions: Gavi, the Vaccine Alliance in 2000; the Global Fund to Fight AIDS, Tuberculosis and Malaria in 2002; and the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003. These new commitments and partnerships helped to define the contemporary landscape of global health cooperation.Reference Gostin 4
However, the 2016 election of President Trump subverted US engagement in international affairs, setting America on a nationalist path. Pursuing an “America First” agenda, the first Trump administration defunded, withdrew, and disengaged from several UN agencies and bodies; attempted to make substantial cuts to foreign health assistance; and undermined international efforts to respond to the COVID-19 pandemic. With the COVID-19 response exposing the limitations of nationalist approaches to global health challenges, the Biden administration quickly reversed some of these decisions, but the 2024 reelection of President Trump has returned the United States to a path of populist nationalism that poses a formidable challenge to global health.Reference Meier 5
US Policy Shifts Threaten Public Health, Foreign Assistance, and Global Governance
Over the past year, the second Trump administration has undermined health science, dismantled foreign assistance, and threatened global solidarity — eroding US global health leadership.Reference Gostin 6
Rejecting Public Health Science
The administration has embraced an extreme anti-science ethos that imperils trust in public health and rejects the evidence base foundational to sound health policy. Under Health and Human Services (HHS) Secretary Robert F. Kennedy, Jr., the administration has stifled health advancements by curtailing research funding, undermining independent review processes, and promulgating health misinformation.Reference Gostin 7 It has sought to realign public health institutions to meet ideological priorities rather than scientific conclusions — through cuts to research budgets, privatization of government services, and threats to university research and scientific inquiry.Reference Broad 8 Health researchers now report a “climate of fear” marked by job losses, abandoned research, political censorship, and government-driven misinformation.Reference Kozlov 9
The United States is rapidly losing its longstanding leadership in health science and innovation. Within NIH, political appointees have limited funding applications, suspended grant reviews, terminated health research, and reduced training opportunities. CDC has similarly seen its mandate narrowed, its scientific independence curtailed, its journal articles removed, and its international collaborations upended.Reference Greer 10 In line with the “Make America Healthy Again” movement, the Food and Drug Administration has embraced scientific misinformation to limit vaccine access.Reference Yamey and Beyrer 11 Specifically targeting climate science, the Trump administration is seeking to deregulate corporate pollution, undermine environmental health research, and promote the burning of fossil fuels, with the Environmental Protection Agency now denying the threat of climate change.Reference Brady 12
Slashing Foreign Assistance
Beyond this sharp contraction of health science, the administration has slashed foreign health assistance, diminishing US power and endangering lives worldwide. Under the leadership of Secretary of State Marco Rubio, the “America First Global Health Strategy” 13 (AFGHS) has consolidated foreign health assistance under the State Department. Although the AFGHS nominally pledges continued support for major infectious-disease programs and investments in pandemic preparedness, it ties foreign assistance to advancing US innovation and economic interests; favors bilateral deals over multilateral institutions; and conditions funding on data sharing — effectively reframing global health as an instrument of national security and geopolitical competition.Reference Okereke 14
In line with a broader agenda to cut government programs, the administration’s Department of Government Efficiency has shuttered thousands of humanitarian health projects, withdrawn lifesaving services to millions,Reference Westfall 15 and created a funding vacuum that no other donor can fill. Emblematic of this dismantling of US foreign assistance, the administration dissolved USAID — under the guise of eliminating “inefficiencies” — and unilaterally halted congressionally appropriated global health funding. The administration has similarly targeted PEPFAR with funding freezes, stop work orders, and narrow waivers for only specific instances of care, resulting in vast gaps in HIV prevention, testing, and treatment,Reference Friedman 16 and the expectation of an additional 4 million AIDS-related deaths by 2029. 17
Furthering conservative ideology in foreign policy, the reinstated Global Gag Rule has cut funding to all organizations that provide, counsel for, or even discuss abortion, restricting access not only to abortion-related services, but also to a broad range of essential sexual and reproductive healthcare services. 18 The administration has correspondingly reentered the anti-abortion “Geneva Consensus Declaration,” aligning itself with other conservative states seeking to restrict reproductive and LBGTQ rights in global governance. Together, these cutbacks have decimated the foundations of US foreign health assistance, impacting nations throughout the world and threatening the global order for health.
Threatening Global Governance
The administration has further undermined global health governance by withdrawing from international organizations, slashing its funding commitments, and neglecting global agreements — with disastrous consequences for global health and US health security. Driven by increasing nationalism in international affairs, the Trump administration has withdrawn from multilateral institutions under claims that these organizations have acted contrary to US interests.Reference Gostin and Meier 19 As the US burns bridges in global efforts to promote public health, it is relinquishing its leadership in global institutions in ways that have threatened the lives of millions and shaken global confidence in US leadership.
On the first day of the new administration, President Trump withdrew from WHO, 20 at once forfeiting access to technical data from WHO partnerships and US influence in global health governance.Reference Yazdi-Feyzabadi 21 This abandonment extended to WHO’s global health law reform efforts, rejecting 2024 amendments to the International Health Regulations (despite US leadership in negotiating these reforms) and withdrawing from multilateral negotiations leading to the adoption of the 2025 Pandemic Agreement.Reference Pace and Kim 22
The United States has similarly pulled all support from Gavi — driven by HHS Secretary Kennedy’s anti-vaccine ideology — jeopardizing a program credited with over a billion childhood vaccinations and over eighteen million lives saved.Reference Cheng 23 Additional cuts and funding freezes to UNAIDS have resulted in “perilous risks” for the global HIV/AIDS response. 24 The administration’s withdrawal for a second time from the Paris Agreement further limits global coordination to address the cataclysmic public health impacts of climate change, creating a permissive environment for carbon emitters. 25
Without ties to multilateral institutions, the Trump administration is rolling out bilateral memoranda of understanding (MOUs) that condition essential US health assistance on expedited sample and genomic data sharing, long-term access to national health databases, and the adoption of American-controlled reporting systems.Reference Cullinan 26 While not expressly exclusive, these MOUs would create structural dependencies that effectively give the United States priority access to pathogens, undermining the system of multilateral pathogen access and benefit sharing (PABS) that WHO Member States are currently negotiating under the Pandemic Agreement. 27
The World Responds
US leadership in global health is not easily replaced. Yet even as this US abandonment has strained global governance, collapsing US leadership in global health, it has opened space for other actors to take on new leadership roles, forge new partnerships, and deepen their commitments to global solidarity in ways that are already reshaping the global health landscape — to the exclusion of the United States.
New Research Centers
With US health research and assistance in decline, other nations are seizing the opportunity to fill the void and expand their global leadership in science and innovation. Focusing on scientific partnerships, and capitalizing on interconnected science networks across Europe, the European Commission in September announced a new strategy to bolster scientific facilities, research, and technology infrastructure to reposition Europe as a global hub for science innovation,Reference Howie 28 and is already pooling resources and knowledge to rapidly increase scientific discovery. 29 Canada’s national academies have developed policy strategies to strengthen Canadian research and innovation systems and global health leadership.Reference Evans 30 In line with its global ambitions, China continues to invest in its research universities and laboratories to accelerate scientific discovery.Reference Qitong 31 These developments signal a redistribution of global scientific influence and the emergence of new global research hubs.
Streamlined WHO Governance
Drastic reductions in US funding have forced WHO to impose substantial (20%) cuts to its next biennium budget — from $5.3 to $4.2 billion 32 — shifting some of its core functions to lower-cost locations, shrinking its program divisions from ten to four,Reference Fletcher 33 and reducing its workforce by over 200 people (with modeling projecting that up to 20% of global staff could still be cut).Reference Fletcher 34 These sweeping cuts will diminish WHO’s overall operational capacity and ability to act as the world’s health leader. Yet WHO continues to maintain the support of its member states through its normative authorities. The adoption of the Pandemic Agreement in May 2025 — establishing a legally binding, multilateral framework for pandemic prevention, preparedness, and response (PPPR) under WHO — illustrates the enduring relevance of WHO governance in the development and implementation of global health law. WHO member states are continuing to expand the normative framework of the Pandemic Agreement in negotiations to finalize its essential PABS Annex. In the absence of active US interference, the benefits of global governance have spread to other international fora, as world leaders at the G20 adopted a declaration addressing the climate crisis and other global challenges despite US opposition.Reference Cocks 35
Rising Global Health Powers
This widening leadership vacuum in global health is creating new opportunities for other nations.Reference Fletcher 36 China has increasingly sought to deepen its leadership in global health under its Health Silk Road strategy, expanding its global influence through bilateral technical cooperation and health assistance.Reference Killeen 37 China has provided crucial support to Africa CDC, and pledged an extra $30 million to WHO after the US withdrawalReference Jin 38 — even if this figure is far from covering WHO’s financing gap.Reference Husain and Sullivan 39 Similarly, several European nations are continuing their strong support for multilateral institutions and global health, as seen in Germany’s investments in WHO’s pandemic intelligence functions,Reference Negri 40 France’s support for WHO workforce capacity building, and targeted foreign assistance from Nordic countries.Reference Jensen 41 Still, many European nations have simultaneously cut their official development assistance, compounding the retrenchment of US global health assistance.Reference Rose 42
Reduced US dominance has also created diplomatic and funding space for Global South initiatives. Lack of solidarity in the COVID-19 pandemic underscored the need for greater African health sovereignty, and governments across Africa have since committed to strengthening the institutions and capacities long constrained by dependence on external decision-making, foreign assistance, and limited pharmaceutical manufacturing capacities. This shift has been supported by Africa CDC, whose leadership has been essential in responding to outbreaks of mpox and Marburg. Africa CDC has focused on local manufacturing capacity, as seen in the 2022 launch of the Partnerships for African Vaccine Manufacturing Framework.Reference Nkengasong 43 Most transformative will be the New Public Health Order for Africa and its more concrete successor, the 2024 Africa Health Security and Sovereignty Agenda.Reference Kaseya 44 This African leadership — bolstered by the recently launched African Epidemic Fund 45 and the African Medicine AgencyReference Nakkazi 46 — can chart a path toward stronger PPPR capacities, expanded regional pharmaceutical production, and stronger financing. 47 At the August 2025 Accra Health Sovereignty Summit, African leaders launched the Accra Compact, emphasizing the need for health sovereignty through greater domestic investment, stronger governance aligned with African priorities, and regional manufacturing.Reference Ofosu 48
Reasons for Hope amid US Decline
The continuing importance of global health amid a retreat in US leadership offers hope for further advancements in global health law, as evidenced by the rise of new scientific powers, the maintenance of global health governance, and the establishment of new multistate partnerships. These developments offer reasons for hope. While none of these initiatives will replace the leadership, assistance, and cooperation once provided by the US government, the emerging pluralistic global health landscape offers new opportunities to democratize global health priorities, decolonize global health governance, and facilitate global health equity. Global health law will endure. The United States may eventually reengage with the world, but the global health landscape will be fundamentally transformed when it does — creating a system that is more multipolar, more resilient to unilateral shocks, and ultimately far less dependent on, or influenced by, US leadership.
Acknowledgments
The authors are grateful to George O’Hara and Darby McBride for their thoughtful research support in chronicling US policy shifts, and to Eric Friedman for his careful editing and review of this column.
