In July 2020, amid the COVID-19 pandemic, then-President Donald Trump shocked the global health community by announcing the United States would withdraw from the World Health Organization (WHO). Trump falsely claimed WHO had helped China cover up the spread of the virus in the early days of the pandemic.
A U.S. withdrawal didn’t happen, because it requires a 1-year transition period. When President Joe Biden assumed office in January 2021, he quickly reversed Trump’s decision. But Trump will have a second chance to abandon the global health agency after he returns to the White House early in 2025. And given his “America first” motto, some are bracing for major cuts in funding to other international programs on HIV/AIDS, malaria, and other global health issues. Negotiations over WHO’s Pandemic Treaty, a global agreement to better prepare the world for future pandemics, may be doomed as well.
The result will be “more mortality, more illness,” predicts Ilona Kickbusch, a global health expert at the Graduate Institute of International and Development Studies.
At the same time, the only guarantee with Trump is unpredictability. During his first term he also launched Warp Speed, an $18 billion program that developed COVID-19 vaccines at breakneck speed—even though he later distanced himself from the effort and has embraced vaccine skeptic Robert F. Kennedy Jr. And although drastic funding cuts in global health would undeniably do damage, a shake-up of the current system could also lead to more sustainable solutions to global health challenges.
For WHO, however, a U.S. withdrawal would be “cataclysmic,” says Lawrence Gostin, an expert in national and global health law at Georgetown University. The U.S. is one of the agency’s largest funders, providing roughly $110 million annually—nearly one-quarter of the worldwide total—and several hundred million in additional voluntary donations. The loss “would absolutely hollow out the agency,” Gostin says. Even if the U.S. doesn’t quit WHO, observers say the new administration could seriously slash its funding, especially if Republicans end up in control of both chambers of Congress, as appears likely.
Funding cuts are also likely to hit the U.S. Agency for International Development (USAID), which helps administer many health-related programs; the National Institutes of Health’s Fogarty International Center, which funds research on global health; and the Global Fund to Fight AIDS, Tuberculosis and Malaria, to which the U.S. is the largest contributor, pledging $6 billion of the $15.7 billion promised in the most recent round of financing in 2022.
Like all Republican administrations since former President Ronald Reagan, the new administration will likely halt funding for the U.N. Population Fund and other organizations that work on reproductive health. And Trump is expected to reimpose the “global gag rule” that blocks funding to foreign organizations that help provide access to abortions. All programs “will be examined to the last word to see whether it could imply any support for abortion,” Kickbusch predicts. “That standard was applied ever more strictly as the first Trump term went on.”
Abortion could also make President’s Emergency Plan for AIDS Relief (PEPFAR) a target. The program, started by former President George W. Bush, works on HIV control efforts in more than 50 countries and has been credited with saving millions of lives. PEPFAR’s $6 billion annual budget has long had bipartisan support, but last year conservative advocacy groups and some Republican lawmakers claimed the program might be indirectly supporting abortions and objected to language in agency documents that referred to transgender people and sex workers, who are at high risk for HIV/AIDS. On the other hand, Project 2025, a governing blueprint by the conservative Heritage Foundation, praised PEPFAR’s focus on distributing money through local organizations and said the model should be replicated across USAID. (Trump disavowed Project 2025 during the campaign, and it is not clear how much influence it will have on his second administration.)
Other countries may partly replace U.S. funding for international health, says David Heymann, an infectious disease epidemiologist at the London School of Hygiene & Tropical Medicine who worked for decades at WHO and the U.S. Centers for Disease Control and Prevention. “Europe is going to have to continue to play a stronger role,” he says. Germany recently boosted its funding and leadership in global health, Heymann notes. The BRICS group of middle-income countries—named after Brazil, Russia, India, China, and South Africa—could also shoulder more responsibility, Kickbusch says, which would be a good thing: “Sometimes disruption forces a rather staid system to actually wake up,” she says. A drastic drop in funding could accelerate efforts to shift from top-down to more bottom-up approaches in global health, several experts say. “Global health should no longer be, ‘We’re raising money and giving it to you,’” Heymann says. “It should be, ‘You tell us what you need, and we’ll help you.’”
A shrinking role for the U.S. will carry risks as well, because the countries that replace it will seek to benefit diplomatically. China and Russia used the COVID-19 vaccines they developed to strengthen ties with other countries, for example, and China’s Belt and Road Initiative, which focuses on infrastructure but also has health components, has drawn many countries into its sphere of influence. “From a national security standpoint, I would find it surprising if the U.S. government would take the risk of not being an important voice and player in this system,” says John-Arne Røttingen, CEO of the Wellcome Trust and a former special adviser to WHO.
Gostin predicts Trump will “torpedo” WHO’s pandemic treaty, still in development after global negotiations failed to produce an agreement in time for the World Health Assembly in May. The main sticking point is a system that would give developing countries guaranteed access to vaccines, treatments, and diagnostics in return for access to pathogens and their genetic sequences. Many pharmaceutical companies oppose such provisions.
But in the end, even a second Trump administration has an interest in preventing a new pandemic—or mitigating the impact if one occurs—and being prepared requires some level of international collaboration, Røttingen says. “Health security is likely to still be high on the agenda,” he says.
Kickbusch sees another sliver of hope: Trump and his allies are professed fans of innovation, which might bring unexpected benefits. “He always looks for deals. … He’s usually unpredictable, and there might be a number of surprises,” some of them perhaps positive. “I wouldn’t say everything the first Trump administration did was wrong,” she adds. “Warp Speed saved millions of lives. One has to be clear about that.”
