Steep cuts in US government funding have thrown much of the field of global health into a state of fear and uncertainty. Once a crown jewel of US foreign policy, valued at some US$12 billion a year, global health has been relegated to a corner of a restructured State Department governed by an “America First” agenda.
Whatever emerges from the current crisis, it will look very different from the past.
As someone who has spent a 25-year career in global health and human rights and now teaches the subject to graduate students in California, I am often asked whether young people can hope for a future in the field. My answer is a resounding yes.
More than ever, we need the dedication, humility and vision of the next generation to reinvent the field of global health, so that it is never again so vulnerable to the political fortunes of a single country. And more than ever, I am hopeful this will be the case.
To understand the source of my hope, it is important to recall what brought US engagement in global health to its current precipice – and how a historic response to specific diseases paradoxically left African health systems vulnerable.
Disease and dependency
Over two decades ago, the field of global health as we currently know it emerged out of the global response to HIV/Aids – among the deadliest pandemics in human history. The pandemic principally affected people of reproductive age and babies born to HIV-positive parents.
The creation of the US President’s Emergency Plan for Aids Relief (Pepfar) in 2003 was at the time the largest-ever bilateral programme to combat a single disease. It redefined the field of global health for decades to come, with the US at its centre. While both the donors and issues in the field would multiply over the years, global health would never relinquish its origins in American leadership against HIV/Aids.
Pepfar placed African nations in a state of extreme dependence on the US. We are now witnessing the results – not for the first time. The global financial crisis of 2008 reduced development assistance to health, which generated new thinking about financing and domestic resource mobilisation.
Yet, the US continued to underwrite Africa’s disease responses through large contracts to American universities and implementers. This was for good reason, given the urgency of the problem, the growing strength of Africa’s health systems as a result of Pepfar, and the moral duty of the world’s richest country.
With the rise of right-wing populism and the polarising effects of COVID-19, global health would come to be seen by many Americans as an elite enterprise. The apparent trade-off between public health countermeasures and economic life during COVID-19 – a false choice to experts who know a healthy workforce to be a precondition for a strong economy – alienated many voters from the advice of disease prevention experts. The imperative to “vaccinate the world” and play a leadership role in global health security lacked a strong domestic constituency. It proved no match for monopolistic priorities of the pharmaceutical industry and the insularity and economic anxieties of millions of Americans.
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This history set the stage for the sudden abdication of US global health leadership in early 2025. By the time the Department of Government Efficiency came for USAID, many viewed global health as a relic of the early response to HIV/Aids, an excuse for other governments to spend less on health, or an industry of elites. The field was an easy target, and the White House must have known it.
Yet therein lies the hope. If global health came of age around a single disease, an exercise of US soft power, and a cadre of elite experts, it now has an opportunity to change itself from the ground up. What can emerge is a new global health compact, in which African governments design robust health systems for themselves and enlist the international community to assist from behind.
Opportunity to build back better
To build a new global health compact for Africa, the first change must be from a focus on combating individual diseases to ensuring that all people have the opportunity for health and well-being throughout their lives. Rather than allowing entire health systems to be defined by the response to HIV/Aids, tuberculosis and malaria, Africa needs integrated systems that promote:
- primary care, which brings services for the majority of health needs closer to communities
- health promotion, which enables people to take control of all aspects of their health and well-being
- long-term care, which helps all people function and maintain quality of life over their entire lifespan.
No global trend compels this shift more than population ageing, which will soon engulf every nation as a result of lengthening life expectancy and declining fertility. As the proportion of older adults grows to outstrip that of children, societies need systems of integrated healthcare that help people manage multiple diseases. They don’t need fragmented programmes that produce conflicting medical advice, dangerous drug interactions, and crippling bureaucracy. Time is running out to make this fundamental shift.
Second, there is a need to shift the relationship between low-income and high-income nations towards shared investment in the service of local needs. This is beginning to happen in some places, and it will require greater sacrifices on all sides.
Low-income governments need to spend a higher percentage of their GDP on healthcare. That will in turn require addressing the many factors that stymie the redistribution of wealth, from corruption to debt to lack of progressive taxation. The US and other high-income countries need to pay their fair share, while also sharing decision-making over how global public goods, from vaccines to disease surveillance to health workers, are shared and distributed in an interconnected world.
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Third, there is need to change the narrative of global health in wealthy countries such as the US to better connect to the concerns of voters who are hostile to globalism itself. This means addressing people’s real fears that public health measures will cost them their job, force them to close their business, or advance a pharmaceutical industry agenda. It means justifying global health in terms that people can relate to and agree with – that is, helping to save lives without taking responsibility for other countries’ health systems.
It means forging unlikely alliances between those who believe in leadership from the so-called global south and those who take an insular view of America’s role in the world.
Leading from behind
Make no mistake. I am not counting on this – or any – US administration to reinvent global health on terms that are more responsive to current disease trends, more equitable between nations, and more relevant to American voters.
But nor would I want them to. To create the global health for the future, the leadership must come not only from the US, but rather from a shared commitment among the community of nations to give and receive according to their capacities and needs. And that is something to hope for.
Jonathan E. Cohen does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
Black Hole Necromancer
Thanks for this post – I have had a great time visiting your site and find myself now wanting to physically visit South Africa. Well Done!
Steel Cut Toe
Boet – brother. This term is usually used in reference to a male friend or companion.Example: “Hey my boet, see you at the game tonight!”