Fracturing global health with the stroke of a pen

Global healthcare aid is in peril as President Trump reshapes America’s humanitarian work around the world. Bette Browne reports

iWth dizzying speed, US President Donald Trump has upended America’s position as the leader in funding global humanitarian aid. Experts believe that the decision is already having devastating consequences and weakening the country’s ability to protect the health of Americans at home.

The shockwaves for global health began the day the President assumed office on 20 January, when he issued an executive order signalling the intention to withdraw the US from the World Health Organisation (WHO).

Another order froze most US foreign aid for a 90-day review. Days later, his cost-cutting advisor, Mr Elon Musk, began to dismantle the US Agency for International Development (USAID), laying off most of its employees, pausing many of its funding activities, and moving other sections inside the State Department.

It was seen by experts as a hammer blow to humanitarian programmes. Before President Trump took office, the US had been the largest donor of foreign aid in the world. It provided $72 billion (€69 billion) globally in 2023, representing 1.2 per cent of the $6 trillion US budget.

It should be noted, as the Pew Research Centre points out, that this aid also includes military funding.

“Ukraine was the single-biggest recipient of US aid in fiscal 2023, receiving $16.6 billion to help it fend off Russia’s invasion and keep its government and society running,” according to Pew. “Israel, regularly one of the top aid recipients, got $3.3 billion in military aid in fiscal 2023, on par with recent years. Other major recipients included Ethiopia, Jordan, Egypt, and Afghanistan.”

In 2023, USAID distributed nearly $44 billion (€42 billion) of the aid globally. Prof Lawrence Gostin (PhD) told the Medical Independent (MI) he believed the President’s moves are disastrous for world health. “I believe that pulling out of the WHO is a grievous wound to global health,” said Prof Gostin, Professor of Global Health Law at Georgetown University, Washington and Director of the WHO Collaborating Centre on Public Health Law and Human Rights.

In his executive order, President Trump criticised the WHO for what he alleged was its “mishandling” of the Covid-19 pandemic and for seeking what he called “unfairly onerous payments” from the US. Washington is by far the WHO’s biggest financial backer. The US provided about a fifth of the agency’s budget – roughly $1.28 billion (€1.22 billion) – in 2023.   

“Since the US funds roughly 20 per cent of WHO’s already insufficient budget, this means it will entail deep cuts to many of WHO’s programmes and activities such as its health emergencies programme and polio eradication campaign,” Prof Gostin said in response to emailed questions from MI. The health emergencies programme, headed by Irishman Dr Mike Ryan, helps countries respond to and recover from natural disasters and disease outbreaks. The polio eradication campaign protects children around the world from polio and seeks to eradicate the disease.

“It will also affect partnerships and technical support for building health system capacities in lower-income countries, especially in Africa,” Prof Gostin said. “It will undermine all the WHO’s global health norms such as the International Health Regulations and negotiations for a pandemic treaty.” Negotiations to secure this treaty began in 2021 and had been due to be completed in May this year at the World Health Assembly.

The President’s executive order said the administration would cease negotiations on the WHO pandemic treaty while the withdrawal is in progress. He is moving quickly to implement his plan, even though there is a 12-month notice period for the US to leave the agency and stop all financial contributions.

Founding member

The US was a founding member of the WHO in 1948 and has been shaping its work since then, alongside 193 other member states. The agency funds medical research and provides emergency aid during pandemics and other global health emergencies, helping to stop disease threats from spreading across borders.

President Trump’s last move to exit the WHO in 2020 was reversed by former
President Joe Biden. But now he has a secure mandate and time is on his side.

The US departure is putting at risk key programmes like those tackling tuberculosis, as well as HIV/AIDS and other health emergencies. But it will not just weaken the organisation and global health security – it will also have consequences for Americans at home, the WHO emphasised. 

“For over seven decades, WHO and the US have saved countless lives and protected Americans and all people from health threats. Together, we ended smallpox, and together we have brought polio to the brink of eradication. American institutions have contributed to and benefited from membership in WHO,” the WHO said in a statement after President Trump’s announcement.

Prof Gostin also wrote on ‘X’ that he believed President Trump’s withdrawal from the WHO would leave Americans vulnerable, as US health agencies and pharmaceutical companies rely on WHO data for vaccines and therapies. “He’s unravelling US engagement and funding now. That’s unlawful and a grave strategic error,” he wrote. “Trump could be sowing the seeds for the next pandemic.”

Foreign aid freeze

While the US announcement was swift, it was hardly surprising given the President’s move in 2020. The freeze on most foreign aid for 90 days (until April) – while the administration “evaluates current aid programmes” – was even more dismaying for aid workers.

After President Trump announced the freeze, US Secretary of State Marco Rubio issued waivers for “life-saving humanitarian assistance”, which included “core life-saving medicine, medical services, food, shelter, and subsistence assistance”. However, aid workers and United Nations (UN) officials told Reuters the waivers had sparked widespread confusion, along with fears that their US funding would never be restored.

Two workers with aid organisations in Myanmar said they didn’t know whether US-funded food distribution in the country was covered by a waiver. One of the workers described the situation as “mayhem”. Myanmar faces a severe food crisis due to natural disasters as well as a civil war. An estimated two million people in the country are on the brink of famine, according to the UN.

Refugees also bore the brunt of the aid freeze in Bangladesh, where the US funds about 55 per cent of assistance to more than a million Rohingya from Myanmar living in squalid camps. In Africa, humanitarian workers were due to start anti-malaria spraying campaigns in Ghana and Kenya before mosquito populations explode during the rainy season, but insecticide and mosquito nets were stuck in warehouses because of the freeze.

The problems were exacerbated by turmoil at USAID, which appears to be the hardest hit government agency. President Trump gave the go-ahead for Mr Musk and his team from the Department of Government Efficiency to pause or halt the flow of foreign aid and dismantle almost the entire apparatus responsible for administering and distributing aid. “USAID is a criminal organisation,” Mr Musk wrote on ‘X’ on 2 February, offering no evidence for this allegation, and adding “Time for it to die.” The agency’s estimated 10,000 employees, some in the US and others abroad, were cut to just a few hundred people.

Some of USAID’s programmes are coming under the State Department, but if the agency closes permanently, it could mean a drop of about $40 billion (€38 billion) in international aid from that agency per year. The US funded about 47 per cent of the world’s humanitarian initiatives in 2024, according to UN data. The Irish charity GOAL was awarded more than €100 million by USAID in 2023, according to GOAL’s annual report.

“USAID is the largest development funder in the world. It has a presence in about 100 countries,” Prof Gostin told MI. “This will mean that children go hungry and risk stunting, disease will go unchecked, and countless people will suffer from humanitarian emergencies.” 

International aid agencies have warned that reduced funding will lead to the collapse of many assistance programmes in conflict zones, especially in countries such as Yemen, South Sudan, and Syria, where millions of people depend on international aid.

Suspending programmes like President’s Emergency Plan for AIDS Relief would leave 21 million people without treatment, reversing many of the gains that have been made. “Any interruption to HIV services and treatment is deeply distressing to people in care and an emergency when it comes to HIV treatment,” according to a statement on 13 February by Mr Tom Ellman, Director of the South Africa Medical Unit at MSF Southern Africa. “HIV medicines must be taken daily or people run the risk of developing resistance or deadly health complications.”

Prof Gostin agreed. “There is uncertainty as to whether they are allowed to provide medication and even if they can, there is a freeze on funding for health workers and clinics that are needed to administer the medications,” he informed MI.

Mr Pio Smith, the Asia-Pacific Regional Director of the United Nations Population Fund, also said in a statement that in Afghanistan alone, the absence of US support could lead to 1,200 maternal deaths and 109,000 additional unwanted pregnancies between 2025 and 2028.

‘Irreparable harm’

In a statement on 1 February, Ms Abby Maxman, CEO and President of Oxfam America, said that dismantling USAID would have deadly consequences for millions of people living in humanitarian emergencies and extreme poverty.

“This move would mean that while US foreign assistance could continue in some form, President Trump would be recklessly throwing away USAID’s critical experience and strategic focus on saving lives. It has brought life-saving medicines, food, clean water, assistance for farmers, kept women and girls safe, promoted peace, and so much more over decades, all for 1 per cent of our federal budget. Ending USAID as we know it would undo hard-earned gains in the fight against poverty and humanitarian crisis and cause long-term, irreparable harm.”

US courts and to a lesser extent Congress have sought to block or delay the moves by the Trump administration and Mr Musk’s agency, but with limited success. “Before our very eyes, an unelected shadow government is conducting a hostile takeover of the federal government,” Senate Democratic Leader Chuck Schumer said at a protest outside USAID on 3 February. It was a sentiment echoed the same day by a government agency official who told The New York Times: “Before Congress and the courts can respond, Elon Musk will have rolled up the whole government.” 

While polls show support for the President’s moves against USAID, this could change if it impacts the lives of more Americans at home. The Centres for Disease Control and Prevention (CDC) is acutely aware of this point. “Global health security is national security,” its website states. “In today’s interconnected world, a disease threat anywhere is a threat everywhere – and outbreaks can disrupt American lives and livelihoods even if they never reach America’s shores.” The CDC has over 60 offices around the world.

Under the Trump administration, however, making the argument that safeguarding the health of Americans is inextricably linked with the work of global health agencies has become more difficult. Just days after President Trump issued his executive order signalling the withdrawal of the US from the WHO, CNN reported that staff at the CDC had been ordered to stop communicating with the Organisation.

The two agencies work together on worldwide efforts to monitor and contain influenza, for example, and WHO runs the Global Influenza Surveillance Network. Mr Josh Michaud, Associate Director for global health policy at the Kaiser Family Foundation health research group, told NPR radio that it may be challenging for the US to develop annual flu vaccines tailored to the circulating viruses if scientists do not have access to the samples provided through the WHO system. Prof Gostin agreed. “It’s very hard for me to see any US national interest that’s being advanced here. And quite the contrary, I just think it’s making it very hazardous for Americans.”

Some Republican lawmakers in the farming state of Kansas are also concerned about the impact of the aid freeze on farmers who provide US-grown commodities for USAID programmes. They fear that the freezing of funding in more than 100 countries is jeopardising the $2 billion Food for Peace programme, which has been purchasing  commodities from American farmers for distribution overseas for over 70 years.

Kansas Republican Senator Jerry Moran said he was working with other Congressional Republicans to protect Food for Peace by moving it to the US Department of Agriculture.

“In rural America, food assistance programmes like Food for Peace put American-grown products in the hands of the hungry and this food is a tangible extension of the hard work and dedication of farmers and ranchers,” he said in a Senate speech on 13 February. “Food for Peace bolsters the farmers who feed us, creates a more stable world, and feeds the hungry.”

Intensification

However, the cost-cutting measures have only intensified. By mid-February, the CDC began to be targeted. Approximately 1,300 CDC employees, representing about 10 per cent of the agency’s staff, were told they would be losing their jobs. Democratic Senator Jon Ossoff denounced the cuts.

“Indefensible, indiscriminate firing of more than 1,000 CDC personnel in a single day leaves Americans exposed to disease and devastates careers and livelihoods for the world’s most talented doctors and scientists,” he said on the Senate floor on 12 February.

“If this administration guts and gags the CDC, who is going to defend the nation from Ebola? Who is going to protect kids from measles? Who is going to save us from TB?”

The CDC is one of 13 agencies within the US Department of Health and Human Services (HHS), which is now headed by Mr Robert F Kennedy. In an interview on Fox News on 13 February, the day after he was confirmed, Mr Kennedy was asked if half the HHS staff would be losing their jobs.

“I don’t know anything about 50 per cent of people being cut,” Mr Kennedy said. “I would be surprised if there were 50 per cent cuts.”

The HHS employs more than 80,000 people. Besides the CDC, the other large agencies include the National Institutes of Health (NIH) and the Food and Drug Administration. Before his confirmation, Mr Kennedy said he planned to cut hundreds of employees in the NIH, which oversees billions in health research grants to US universities. He has charged that the agency has overemphasised infectious diseases and underemphasised chronic ones – a position that has alarmed public health experts worried about his anti-vaccine claims.

The HHS also provides health coverage through the Medicare insurance programme for over 60 million older Americans and the Medicaid programme for over 80 million low-income groups and people with disabilities. Mr Musk confirmed his interest in the Centres for Medicare and Medicaid Services (CMS), which runs both programmes. On the day Mr Kennedy was confirmed, Mr Musk wrote on ‘X’ that Medicare was “where the big money fraud is happening”. He offered no evidence to support his allegation.

The CMS spent more than $1.5 trillion in 2024, around 22 per cent of federal spending. Both programmes are very popular among both Republicans and Democrats. In response to Mr Musk’s charges, more than 30 Democratic senators signed a letter to President Trump urging his administration not to make cuts to Medicaid and Medicare.

“We strongly oppose any efforts by Musk – or anyone else in your administration – cutting or damaging these vital programmes,” they wrote. “Medicare and Medicaid must not be raided to pay for tax cuts for billionaires.” 

As the impact of such cost-cutting moves continues to derail efforts to assist global health programmes, some fear that much damage will be done as President Trump’s agenda is implemented over the coming months and years.

Prof Gostin fears the consequences will be both profound and tragic.

“If you combine withdrawing from WHO and the decimation of USAID, it is a deep blow to global health and development. The needless suffering and deaths caused will be incalculable.”