Global health is likely to be radically altered with Donald Trump in the White House. For starters, the president-elect has made no secret of his dislike for the World Health Organization (WHO), so a complete withdrawal from the WHO is now a real prospect.
Even if this can be avoided through negotiation, serious and deep changes will be demanded. In one sense, this is long overdue. The WHO’s failure to evolve with the times as well as its sclerotic structure have left it wide open to reform for some time.
But it’s not just the WHO that Trump objects to. He views most multi-country agreements with suspicion. For example, the pandemic treaty – which aims to redress the inadequacies of the global COVID response – he sees as disadvantaging the US.
Indeed, any initiative perceived as either pandering to “woke” interests – for example, gender-sensitive global health programmes – or not directly aligned with Trump’s new foreign policy will be put to the sword. There is a serious threat that the new administration will no longer see global health security as a critical national interest.
The global health and development community – The Global Fund, Pandemic Fund and other organisations such Green Climate Fund – is seeking an unprecedented level of replenishment in the order of US$100 billion (£78 billion). America’s contribution to WHO alone amounts to US$700 million. The scale of the US’s defunding of existing global health programmes is unknown, but it will be substantial.
In theory, major funders, such as the Bill and Melinda Gates Foundation, Germany and the UK could step in to fill these funding gaps. However, the political and global pressures (wars in Ukraine and the Middle East), as well as serious domestic political issues (the UK Labour government has not increased overseas development assistance due to massive deficits), make this unlikely.
Meanwhile, China has quietly become one of the most influential countries on the global health scene through funding healthcare infrastructure and training healthcare professionals. It is plausible that Beijing will step in both to rescue the WHO and some specific global health funds. However, it is highly unlikely that it will save any initiatives it sees as too western, such as Pepfar, a US government programme that aims to stop the HIV/Aids pandemic.
China will probably continue to engage in bilateral and regional development strengthening. Any move by China to further dominate the global health landscape through the belt and road initiative, a global China infrastructure development strategy, is essentially an expansion of its “soft power”. With a US withdrawal from global health, the opportunity presents itself for China to further expand its global health soft power agenda, particularly across sub-Saharan Africa.
The wider humanitarian agenda from the UN refugee agencies, UNHCR and Unwra, as well as organisations such as Médecins Sans Frontières, will also find themselves on the wrong side of the ideological rail tracks. Increasingly, they will need to look to Europe and other non-aligned countries for support.
Domestic US health policies also have significant global ramifications. The US Centers for Disease Control and Prevention, the Food and Drug Administration (FDA), and the National Health Institute will see new leadership to align with the new administration. Biden-era programmes, such as Cancer Moonshot, an initiative to accelerate scientific discovery in cancer research, foster greater collaboration and improve the sharing of cancer data, will be terminated.
Many other global health and development programmes are likely to be cut. For example, the UN Population Fund (UNFPA) could lose more than US$160 million.
Despite Trump’s promise to get tough on domestic drug prices, his pro-business agenda will probably mean that the FDA will continue to lower the bar required for new drug market authorisation. The effect of these decisions by the FDA will be felt far and wide through Project Orbis, a US-led global collaboration to promote faster authorisation and access to cancer drugs.
Biopharmaceutical pipelines, dominated by cancer drugs, will flood European and wider markets with medicines with even greater uncertainty around true benefits and toxicities, with even greater costs. Regulatory agencies, such as the European Medicines Agency, will have to decide whether it is in the European interest to continue to align with the US through Project Orbis.
Global acceleration of privatised healthcare
Trade deals in the Trump era will also mean the downgrading of any public health considerations as well as the demand to open up domestic markets to US private healthcare companies. For many countries, this will be anathema to their national systems and policies, but for those countries in weaker positions, doing business with the US will accelerate the privatisation of health, making universal health coverage even more untenable.
Multilateral development banks such as the World Bank and African Development Bank will need to rethink their global health priorities in a world with a smaller US global health footprint. Europe will need to seriously reflect on its commitment to global health and development with a greatly diminished US contribution. This could include looking further east, for new cooperative partnerships with China, Japan and South Korea.
With all change comes opportunity. Overseas development assistance has been wasteful and disconnected from new challenges as well as actual country needs. Non-communicable diseases, especially cancer, are not on the global agenda when they should be. The global health community has been too concentrated on disease priorities set by the liberal US agenda while failing to strengthen horizontal health services (health services that cut across disease domains), such as surgery.
Alignment of global health with wider security interests is also needed. In today’s polycrisis world, classic humanitarianism is not the route to solving complex global health problems. Above all, a Trump presidency should be the start of a serious realignment of global health priorities, not just to an attempt to fill in the loss of US funding, but to restructure the world’s approach to health and development.
Richard Sullivan receives funding from UKRI, NIHR and the Global Alliance for Chronic Diseases.