The Consequences of US Retreat From the Global Health Security Leadership

Background

Upon returning to the Oval Office in 2025 for a second term, the Trump Administration initiated major reforms in health security domains with an “America First” agenda, resulting in a significant departure from decades of US engagements in this sector. The United States officially withdrew from the World Health Organization (WHO) on January 20, 2025, echoing a previous attempt in 2020. ¹ This decision was based on claims that WHO mishandled the COVID-19 pandemic, failed to institute reform, lacked independence, and placed unfair financial burdens on the United States. Simultaneously, the US Department of Health and Human Services (HHS) experienced a significant restructuring due to substantial budget cuts that necessitated the elimination of approximately 20,000 employees and the closure of entire agencies. ² One example was the ultimate elimination of the HHS United States Agency for International Development (USAID), which began with the termination of over 86% of its financial awards, leading to the dismissal or leave of thousands of agency and project staff in the United States and abroad. A 90-day freeze on foreign development assistance, including global health programs, was implemented, causing disruptions to essential health services and potentially reversing years of progress against emerging health security risks across the globe.

Health security risks are real, requiring careful monitoring and timely response. This is especially true when the world is recovering from the height of the COVID-19 pandemic, with lessons indicating the need for robust health security national and global preparedness. ³ Within the last year, the United States has also experienced the emergence/reemergence of bird flu, mpox, measles, dengue fever, and the Oropouche fever. ⁴ A recent ecological niche modeling study delineated high-risk zones for Oropouche virus transmission throughout Central and South America, revealing a complex interplay between environmental conditions and the virus’s spread. ⁵ Given the cross-border transmission of these emerging/reemerging diseases, health security preparedness requires both local and collective global actions through leadership.

The United States has historically occupied a central, influential position in the global health security landscape. Unlike many high-income nations, the United States dominated this through leadership and care, with significant financial contributions, shared technical expertise, and the establishment and support of numerous international health initiatives. ⁶ This leadership has been underpinned by a bipartisan consensus recognizing the importance of global health as both an extension of American values and a critical component of its soft power, enhancing its standing and influence on the world stage. Over the last few decades, this commitment has translated into tangible progress in combating infectious diseases, strengthening health systems in low- and middle-income countries (LMICs), and fostering international cooperation to address shared health challenges.

However, the notable shift in US policy by the second Trump administration has already had a profound impact on the established global health architecture, generating a cascade of tangible and intangible consequences across various domains in the short, medium, and long term (Table).

Risk of Rising Preventable Diseases and Inequality

The immediate consequence of the reduction of US leadership in global health security is a significant funding crisis for key international health organizations, most notably WHO. The United States has historically been the largest single contributor to WHO, providing between 12% and 22% of its total budget.^7,8 The abrupt cessation of these contributions has forced WHO to initiate stringent austerity measures, including hiring freezes, budget cuts, and reduced operational expenses. This financial shortfall directly threatens WHO’s global health security capabilities, such as coordinating responses to health emergencies, conducting global disease surveillance, and providing technical assistance to member states.

Beyond the impact on multilateral organizations, bilateral aid and programs have been significantly disrupted, particularly those through USAID. ⁹ The administration's 90 day freeze on USAID funding and the termination of nearly 5,800 contracts have affected a wide array of global health programs and people engaged in them. ¹⁰ This has resulted in the layoffs of numerous health workers and researchers, both American and others, within the United States and across the globe. For example, Johns Hopkins University alone had to significantly reduce over 2,200 positions, 1,975 roles in 44 countries and 247 in the United States, after over $800 million in USAID grants were terminated. ¹¹ The eliminated programs addressing critical health areas such as HIV/AIDS (through the President’s Emergency Plan for AIDS Relief [PEPFAR]), malaria (through the Presidents Malaria Initiative), tuberculosis (TB), maternal and child health, and neglected tropical diseases have experienced immediate setbacks, affecting disease control efforts and leading to significant mortalities and morbidities in LMICs. ¹² Moreover, the abrupt cessation of this bilateral support resulted in immediate disruptions to essential health services in LMICs, including the delivery of vital healthcare, jeopardizing the health and lives of millions of vulnerable individuals. ¹³

These actions are likely to result in a resurgence of preventable diseases as medium-term consequences. Disruptions to longstanding vaccination programs, particularly in LMICs, could lead to outbreaks of diseases such as measles, polio, and diphtheria, reversing years of progress in immunization coverage and progress toward disease control and potential elimination. ¹⁴ The fight against major global health threats like HIV/AIDS, TB, and malaria will face significant setbacks, potentially leading to increased drug resistance and higher mortality rates.

Significant reductions in international funding for HIV programs, particularly from 5 major donor nations, are predicted to result in a substantial increase in new HIV infections and related deaths in Sub-Saharan Africa between 2025 and 2030. A modeling study utilizing country-validated Optima HIV models across 26 Sub-Saharan African nations highlights the potential impact of these funding shortfalls. ¹⁵ The study indicates that a combination of reduced international aid and the discontinuation of support from the PEPFAR could lead to an estimated 4.43 million to 10.75 million additional new HIV infections and 0.77 million to 2.93 million additional HIV-related deaths over the 5-year period. However, the research also suggests that if PEPFAR support were to be reinstated or equivalent funding were secured, the projected increase in morbidity and mortality would be significantly mitigated. In such a scenario, the models project a much lower range of additional outcomes: between 0.07 million and 1.73 million new HIV infections and a considerably reduced 0.005 million to 0.061 million HIV-related deaths during the same timeframe. TB data show a similar progression. For Sub-Saharan Africa alone, the funding freeze exacerbates an existing US$11 billion shortfall for TB response, substantially worsening the situation and greatly reducing the chance of meeting the United Nation’s targets of ending tuberculosis by 2030. ¹⁶

By drastically reducing or eliminating funding, health inequities among LMICs will widen. These countries, which have historically relied heavily on US funding and technical assistance for their health programs, will face significant challenges in sustaining their efforts without consistent external support. This will likely exacerbate existing health inequities between high-income countries and LMICs, leading to disparities in access to care, treatment outcomes, and overall health status. Reduced engagement can impede the development and equitable distribution of critical medical countermeasures, such as vaccines, diagnostics, and therapeutics, leaving the world less prepared for future health emergencies. Furthermore, reduced access to essential healthcare services in LMICs will likely lead to an increase in maternal and child mortality rates, undermining efforts to improve health outcomes for these vulnerable populations. ¹⁷

Shortfalls in Pandemic Preparedness

In an article aimed to guide the US administration on health priorities, 6 actionable recommendations were provided that focused on improving the US’s pandemic response and resilience: ¹⁸ (1) promoting One Health leadership through collaboration across federal agencies, universities, and nonprofits to address health threats from zoonotic diseases; (2) expanding the roles of the US Fish and Wildlife Service to mitigate health risks from wildlife trade; (3) enhancing USAID’s pandemic prevention efforts within and across nations; (4) broadening international collaborations; (5) addressing key disease drivers; and (6) supporting international agreements. Recent US reforms contradict these recommendations, making the pandemic preparedness and response vulnerable. The blow was solidified by massive disruption of National Institutes of Health (NIH) funding, ending crucial research and development work; important vaccine uptake and hesitancy and climate and health research; ¹⁹ and vaccine and antiviral programs aimed at preparing for future pandemics. The recent HHS decision on funding closure of dozens of such studies is a severe setback in this endeavour towards studying and developing effective medical countermeasures. ²⁰

The US withdrawal from WHO also greatly diminishes global surveillance capabilities and early warning networks crucial for detecting and responding to emerging infectious disease threats. The loss of US technical expertise and collaboration in global health security efforts further weakens the international community’s ability to prepare for and respond to pandemics effectively. Precisely here, the Trump Administration made the deadliest decision by closing the CDC’s prestigious Epidemic Intelligence Service (EIS) program, whose scientists were popularly known as the “Disease Detectives.” ²¹ The EIS has been a benchmark for the global communities and a beacon of hope for other nations to aspire, learn, and improve. ²² Although reversed later and the services restored, ²³ the message went out, shaping the perspectives of other countries and projecting an image of inconsistency and a potential retreat of US leadership in the global health sector.

Erosion of Science Diplomacy and Redistribution of Soft Power

The US retreat from global health security support and leadership creates a noticeable shift in global health governance and science diplomacy. The absence of strong US leadership creates a vacuum that other nations will need to fill, potentially reshaping global health priorities and the balance of power within international health organizations. ²⁴ This shift could weaken international cooperation and multilateralism in addressing shared health challenges, as geopolitical considerations may increasingly influence global health agendas.

This could directly impact US strategies in science diplomacy. Historically, the United States recognized science and technology as strategic assets that can bridge diplomatic gaps, even with nations having strained relations. ²⁵ The country used their scientific capabilities and advancements during the Cold War to secure alliances and markets, showcasing the importance of science and technology in foreign policy. ²⁶ However, the new reforms contrast with the United States’s pivotal role in science diplomacy, reducing cooperation on critical health issues and hindering the global scientific community’s ability to tackle complex health problems effectively.

Collectively, these can significantly diminish the United States’s soft power and international influence. This withdrawal can be perceived globally as a selfish and isolationist act, damaging the US image as a benevolent global leader committed to addressing shared challenges. This undermines the trust the United States has built over decades as a reliable partner in addressing global health issues and other international challenges.

Consequently, the United States risks losing its influence among other nations, diminishing its ability to advance its foreign policy objectives and shape global agendas. Due to its diminished participation and influence in forums like WHO, the United States will also have a reduced ability to shape global health agendas and ensure that its interests and values are reflected in international health policies and initiatives. This creates an opportunity for other nations with competing interests to increase their influence in global health governance, potentially at the expense of US strategic objectives.

Implications for US National and Health Security

The closure of US leadership in global health security had significant implications for both US national security and health security. Reduced access to global disease surveillance data and early warning systems due to the withdrawal from WHO potentially delays the US response to emerging health threats, increasing the risk of imported diseases. ²⁷ A weakened global capacity to contain outbreaks at their source, resulting from diminished US support for international health initiatives, increases the likelihood of infectious diseases spreading internationally, posing a direct threat to the health of American citizens. Furthermore, the potential reemergence of diseases that have been eradicated or controlled globally could pose a significant risk to US public health.

Beyond naturally occurring outbreaks, the risk of intentional biothreats, such as bioterrorism or the deliberate misuse of dual-use technologies like AI and synthetic biology, is a significant concern for national and global health security. For a long time, the United States has managed to repel its adversaries by exercising soft power and scientific diplomacy, with global cooperation on biosafety and biosecurity. Moreover, United States’s threat reduction programs have been crucial for responding to emerging threats and filling existing gaps in national security measures. However, the US Department of Defense's plan to reduce the Defense Threat Reduction Agency workforce by up to 75% poses a significant risk. This measure is likely to disproportionately affect the Cooperative Threat Reduction and Biological Threat Reduction Program that could increase vulnerabilities in national biosecurity. ²⁸

Conclusion

The absence of US leadership provides an opportunity for other countries or country unions to fill the gap and make decisions.

Amid rising catalysts of global health security threats, both natural and intentional, humanity is practically living in the age of pandemics. However, few nations have a robust pandemic response system, as is exemplified by the Global Health Security index. ²⁹ With an inability to accurately predict the next pandemic, the only solution lies in global solidarity, where collective global efforts are mandatory over the action of a single country. ³⁰ This requires proactive preparations on all fronts and multidisciplinary action to ensure that any rising threat can be managed effectively.

This also requires continued US support and leadership through increased investment in surveillance networks, strengthened international collaboration, and data-supported decisionmaking. However, the US health security experience under the Trump Administration has not been reliable. ³¹ In their first tenure, the government lost opportunities to manage COVID-19, while the current government risks opening the door for the next outbreak. ³² Thinking the next health emergency will come from a single pathogen could be entirely wrong. Instead, “pathogen collaborations” may result in rippling effects that single agent-based traditional countermeasures will find difficult to address. Simply put, we will need more “human collaboration” to beat the “pathogen collaboration,” which will require rising above politics and reengaging in a global agenda.

While the recent US actions have created a global health vacuum, that vacuum will invariably be filled somehow and by someone. With no change in the status quo, the global community will no longer be able to recognize US relevance and leadership in global health. This reflects in global calls for LMICs to seize this moment as an opportunity to bring self-resilience and autonomy and develop tailored models in health systems, research, and leadership. ²⁴ Irrespective of whatever happens in the future to reverse recent decisions or reforms, it is clear that the global order will definitely change, and global health security will not be the same. In such a shadowed environment, it is important to remain flexible and adaptive to accommodate new norms and go beyond sustainability.

The United States cannot afford to lose its rich human resources and global prestige through this untimely action. If the goal is to make “America Great Again,” global health leadership must be the priority, and the current administration must handle health security sensibly, avoiding past mistakes. ³² The systematic dismantling of established public health infrastructure must stop. Instead of considering health a state affair, health must be seen through the lens of “vasudhaiva kutumbakam.” Penned at the birth of humanity and globalized through the 2023 G20 Summit in India, this Sanskrit phrase advocates a “One World, One Family” view, holding key lessons for global good health and wellbeing.