U.S. Retreat From Global Public Health Signals Major Change In Policy

KFF reports that the United States has far and away been the largest donor country to global public health in the world. But under the Trump administration the U.S. is largely retreating from its role as benefactor. A flurry of executive orders issued by President Trump since his inauguration signal a major departure from previous U.S. foreign aid policy, which was characterized as a wielding of soft power by way of co-option rather than coercion.

The distinguished political scientist Joseph Nye Jr. coined the term soft power in the 1980s. Broadly, it involves influencing other nations through political, moral and cultural appeal. There are many examples of soft power, including international health and food assistance.

For decades, the U.S. has exercised soft power through foreign aid. This involved multiple government agencies and targeted numerous areas of need, including nutrition, tuberculosis, malaria, HIV/AIDS, maternal and child health, family planning and reproductive health and neglected tropical diseases.

The federal government disbursed $71.9 billion in foreign aid in 2023, according to the Pew Research Center. While this is a lot of money, it represents merely 0.6% of the aggregate federal budget.

Funding for global public health initiatives is determined annually in the U.S. The federal government’s budget process is initiated by the President, but Congress is responsible for approving and appropriating almost all of the resources.

Nonetheless, President Trump began his second term by ordering a sweeping 90-day spending freeze on virtually all U.S. foreign aid, including many forms of health and food assistance. An independent agency, the United States Agency for International Development, is perhaps the most visible entity to be severely impacted.

The USAID was established under President John F. Kennedy in the early 1960s to administer humanitarian aid programs around the world on behalf of the federal government. But the entity’s future existence is now in doubt as the Trump administration plans to eliminate more than 90% of USAID contracts. Elon Musk, head of the Department of Government Efficiency, said in a social media post that he and Trump will shut down the foreign assistance agency.

The agency employed roughly 10,000 people in 2024, two-thirds of whom worked overseas. Last year, USAID received more than $44 billion in federal funding. Most of that money is spent in Asia, sub-Saharan Africa and Europe (primarily on humanitarian efforts in Ukraine). While a considerable sum, it accounts for just 0.4% of the entire federal budget.

The Trump administration’s dramatic policy shift on international assistance indicates an unprecedented retreat from the nation’s prominent profile worldwide as a magnanimous benefactor. Nowhere is the change more evident than in the dismantling of USAID.

Atul Gawande, former Assistant Administrator for Global Health at USAID, wrote on X that 5,800 USAID contracts have been terminated in defiance of the courts. In addition, all supplies of U.S.-manufactured emergency food packets, all tuberculosis programs and all donations of malaria supplies protecting 53 million people, mostly children, including bed nets, diagnostics, preventive drugs and treatments, have been discontinued.

Beyond the impacts on USAID, other initiatives, such as the U.S. President’s Emergency Plan for AIDS Relief created by former President George W. Bush in the 2000s, are under threat. During his first week in office, Trump issued an executive order temporarily halting all PEPFAR activities. This program represents the largest commitment by any nation to address a single disease in history. PEPFAR is managed and overseen by the U.S. Department of State’s Office of the U.S. Global AIDS Coordinator and Health Diplomacy.

Secretary of State Marco Rubio signed a waiver on the first of February that allows services to prevent mother-to-child transmission of HIV to resume. But the exemption does not include preventive medicines or other PEPFAR activities. Moreover, as the Guardian reported, the administration last week ended funding for the United Nations program fighting HIV/AIDS.

And Trump’s actions are also affecting what is called the President’s Malaria Initiative, an organization founded by Bush around the same time PEPFAR was established. Through the work of this entity, the U.S. became the world’s largest donor to anti-malaria programs and research. According to the New York Times, one of Trump’s executive orders has led to two-thirds of the staff being let go from the Malaria Initiative.

Additionally, by pulling out of the World Health Organization Trump further shrinks the critical role the U.S. plays in combating neglected tropical diseases, such as leishmaniasis, river blindness, Dengue fever and trachoma. These preventable and mostly treatable infectious diseases affect millions of people in tropical regions of the world, causing severe health problems, including anemia, blindness, chronic pain, infertility and bodily disfigurement. Historically, despite the large burden imposed by neglected tropical diseases on many people, they’ve been allocated a relatively small portion of resources for drug development and treatment distribution. U.S. aid agencies have filled some of the void. Until now.

The famous medical anthropologist and physician Paul Farmer considered healthcare a right. He once wrote that “if access to healthcare is considered a human right, who is considered human enough to have that right?” The implication of his rhetorical question is that everyone, regardless of where they live, ought to have this right.

The ramifications of a greatly diminished U.S. presence in health and food aid, as well as international development and disaster assistance, could be profound and set back the progress that has been made to reduce global health resource and outcome inequalities.