Global Health Insecurity in a Second Trump Term [Guest Essay]
Newsletter Edition #238 [The Files In-Depth]
Hi,
The Trump win is expected to set in motion seismic changes in geopolitics with deep implications for global health.
The impacts are expected to be felt not only in the corridors of World Health Organization in Geneva, but will also reverberate in premier global health agencies, across many ministeries of health, countless partnerships and civil society organizations in many parts of the world.
In today’s guest essay, leading global health legal scholar Lawrence O. Gostin of Georgetown University, lays out for our readers the multi-layer impact of the Trump Presidency.
We will be following developments in Geneva, as geopolitics fuses with the technical aspects of global health, with the potential for shaping the field in definitive ways in the near to the medium term.
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I. GUEST ESSAY
Global Health Insecurity in a Second Trump Term
By Lawrence O. Gostin
Gostin is Distinguished University Professor, Georgetown University and Director, O’Neill Institute for National and Global Health Law, Washington, D.C., USA. He can be reached at gostin@georgetown.edu.
I have worked in global public health since the first cases of HIV were reported in 1980. I have led the WHO Collaborating Center on Global Health Law, and worked in the White House and with US agencies like the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), and the National Institutes of Health (NIH). In all this time, I have never seen a darker day for global health than the election of Donald Trump to a second term.
Trump’s core “America First” values are anathema to the animating principles of global health—mutual solidarity, international cooperation, an abiding concern for marginalized and disadvantaged people, and equitable access to lifesaving public health tools. At his core, Trump disdains international institutions like the World Health Organization (WHO) and global agreements like the International Health Regulations (2005, amended in 2024) (IHR), a future Pandemic Treaty, and the Paris Agreement.
In the next four years, the Trump administration will retreat from global health governance, slash financing, withdraw from international agreements, and direct funds toward anti-health priorities. All of this, and more, will have vast implications for health everywhere but particularly for the world’s most vulnerable.
Here are six areas of global health that will be severely disrupted by a second Trump term.
1. WHO Membership and Financing
During the height of the COVID-19 pandemic, WHO was caught in the midst of a geopolitical conflict between two world superpowers. Trump falsely accused WHO of “siding with China”. And then Trump made what I called the most cataclysmic decision of any US president in my lifetime—giving the UN Secretary-General one year’s notice of the intention to withdraw from WHO. President Biden reversed Trump’s decision on Day One, but now Trump has four years to withdraw if he chooses. Trump is likely to withdraw from WHO, as recommended by Project 2025, widely seen as the hyper-conservative blueprint for a second Trump administration.
That would be disastrous. WHO is the world’s health leader. It has been on the frontlines of nearly every health emergency since its founding, including recently vaccinating children against polio in the Gaza Strip and confronting mpox across Africa.
The U.S. is WHO’s largest Member State funder, representing nearly one-quarter of all WHO assessed dues. Without U.S. funding, or with “greater restrictions on federal dollars to WHO” as Project 2025 outlines, WHO’s programming would be hollowed out, endangering health everywhere.
2. Global Health Treaties
Trump’s distain for the WHO also puts critical WHO pandemic reforms at risk. Let’s begin with the IHR. The U.S. was one of the first movers in proposing IHR amendments in 2022. On the final day of the 2024 World Health Assembly on June 1, U.S. Health and Human Services Secretary Xavier Becerra threatened to walk if the final amendments were not adopted, and they were. That shows the determination and influence of the U.S when it actively engages.
The 2024 amendments will not come into effect until September 19, 2025. As a state party, the U.S. will be bound by the amendments (including the historic guiding principle of equity) without Congressional approval or ratification. But the Trump administration can lodge a reservation (whereby a state reserves the right not to abide by certain treaty provisions) within 18 months of their adoption.
The 2024 Assembly, granted the Intergovernmental Negotiation Body (INB) one further year to negotiate the Pandemic Agreement. The INB recently determined that it will not be able to adopt the Pandemic Agreement at a special session of the World Health Assembly in December as stakeholders and WHO had hoped.
The rush to complete the Pandemic Agreement has been fueled by genuine fears that the Trump administration would torpedo the negotiations. Many Trump allies have stoked disinformation that the Pandemic Agreement would cede authority for domestic pandemic policy to WHO, undermining national sovereignty. These claims have been widely debunked, but are still driving domestic opposition to the Agreement within Make America Great Again (MAGA) circles and even establishment Republicans.
3. Funding for Global Health
The U.S. is currently the largest funder of global health in the world, with a huge network of bilateral and multilateral funding as well as on-the-ground technical assistance and training.
The Institute for Health Metrics and Evaluation reports that the U.S. was responsible for more than 40% of governments’ development assistance for health in 2023, providing more than $20 billion. U.S. global health agencies span from the United States Agency for International Development (USAID) and the CDC’s Center for Global Health through to the Fogarty International Center at the NIH.
The U.S. is a leading funder of core global health initiatives including the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) – 36% of total funding since its launch – and GAVI, the Vaccine Alliance (19% of direct contributions in 2016-2020).
Moreover, the United States supercharges biomedical and behavioral health research, benefiting the world. NIH has a nearly $48 billion budget (2023), and a remarkable track record, including development of the mRNA COVID-19 vaccines. The Fogarty International Center has trained almost 8,500 scientists from low- and middle-income countries since 1989.
There is precedent for Trump slashing global health funding. His budget proposal for fiscal year 2018 would have slashed spending by $2.5 billion, or 23%. Longstanding bipartisan support protected against these cuts, but Republican control of Congress and the election of Trump-friendly MAGA candidates puts these programs at grave risk.
The future of the President’s Emergency Plan for AIDS Relief (PEPFAR) is of particular concern. PEPFAR has invested approximately $120 billion in the global HIV/AIDS response, the largest commitment by any nation to address a single disease in history, saving more than 25 million lives and accelerating progress in more than 50 countries. PEPFAR engages in crucial work supporting sexual health and fighting discrimination. A second Trump administration will, at minimum, put anti-abortion language in the PEPFAR reauthorization bill – perhaps embedding in authorizing language the global gag rule (see below) – or possibly even cut PEPFAR funding.
4. Global Sexual and Reproductive Health
President Trump has taken credit for overturning Roe v. Wade, which undermined sexual and reproductive health and rights. (Roe v. Wade, was a landmark decision of the U.S. Supreme Court in 1973 in which the Court ruled that the Constitution of the United States protected a right to have an abortion, and ruled that unduly restrictive state regulation of abortion is unconstitutional.)
A second Trump term will threaten reproductive rights globally. Experts are “almost certain” that Trump would again cut funding to the UN Population Fund (UNFPA), the UN agency that works to ensure universal access to sexual and reproductive health care. This time the agency stands to lose over $160 million, more than double the amount cut during Trump’s first term.
Trump is likely to reinstate and expand the global gag rule, which would withhold critical health assistance to organizations that provide abortion-related services, even if they use their private funds. During his first term, Trump expanded the domestic gag rule to include all U.S. global health assistance, not only family planning assistance. The impact was documented in devastating detail. Expect a bolstered Trump to quickly reinstate the global gag rule, or even broaden it to cover all U.S. foreign assistance, not only health assistance.
5. Climate Change
Climate change poses an existential risk to global health, with 2024 on track to be the warmest year on record—yet again. But during his second term, Trump’s suite of climate-impacting policies stands to be one of his deadliest and longest-lasting health legacies. In his first term, Trump withdrew from the Paris Agreement on climate change and weakened clean air standards. Expect all this again, but far more. Not only will he again withdraw from the Paris Agreement, but he has pledged to withdraw from the 1992 UN Framework Convention on Climate Change.
Trump’s policies will have a ripple effect across the globe, especially in low- and middle-income countries, which are paying the heaviest price for a problem caused by high-income countries. A slower U.S. clean energy transition, along with little climate financing, will exacerbate climate change and its health impacts.
6. Global Influence of the CDC
The U.S. Centers for Disease Control and Prevention (CDC) will take the brunt of Trump’s ire, given its role during COVID-19. For almost a century, the CDC has engaged in global health diplomacy and action to protect and improve health security. With a network of offices in over 65 countries, the CDC’s work through funding and logistical support, field training, and emergency rapid response helps combat infectious diseases worldwide.
A second Trump term will undercut the agency’s mission, scope, and independence. During Trump’s first term, the CDC faced significant scrutiny and pressure, interfering with CDC operations and censoring its communications.
When Trump returns to office, the CDC will face continued budget constraints and political meddling.
Project 2025 proposes splitting CDC into two agencies: one on data gathering, and another responsible for “limited” public health recommendations. Beyond all that, Trump is expected to empower Robert F. Kennedy Jr., perhaps the world’s most influential and well-funded anti-vaxxer. In the journal Science, I explain the profound impacts.
(See The Guardian: The appointment of Robert F Kennedy has horrified public health experts. Here are his three most dangerous ideas)
Resistance Against the Trump Effect
A second Trump term will have sweeping adverse impacts on global health. Trump’s “America First,” anti-science agenda will be felt everywhere. The next four years will be some of the most dangerous and detrimental to global health in living memory.
Mitigating or preventing the worst impacts of a second Trump term requires fierce mobilization and resistance in the United States and worldwide. The resistance must be political through Congress and the judiciary. It must be bottom-up through social mobilization and peaceful civil society protest, assembly, and action.
And it must be global through the UN and its specialized agencies. Intergovernmental organizations (G7 and G20) and regional blocs (in Europe, Africa, Latin America, and Asia) should not simply fill the void in funding and diplomacy left by Trump, but should vastly increase global health financing and solidarity.
The surest antidote to Trump’s “America First,” is a united world, putting Equity First.
II. PODCAST CORNER
We are here now: youth shaping global health
The world is witnessing its largest youth generation ever, with half of the global population under 30. A sustainable future hinges on the meaningful engagement of young people. In this episode, host Garry Aslanyan speaks with three charismatic young global health leaders.
Inês Costa Louro is a first-year medical doctor from Portugal and the Vice President for External Affairs of the International Federation of Medical Students' Associations.
Aloyce Urassa is a public health scientist from Tanzania and Chairperson of the African Leaders Malaria Alliance Youth Advisory Council.
And Hamaiyal Sana is a Pakistani medical doctor and Vice Chair of the World Health Organization’s Youth Council.
Together, they delve into the crucial role young people are playing in shaping health-related decision-making today and in the future.
Garry Aslanyan is the host and moderator of the Global Health Matters podcast. You can contact him at: aslanyang@who.int
This podcast promotion is sponsored by the Global Health Matters podcast.
If you wish to promote relevant information for readers of Geneva Health Files, for a modest fee, get in touch with us at patnaik.reporting@gmail.com.
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