Donald Trump is just days away from the beginning of his second presidential term. His return to power has the potential to dramatically reshape the global health landscape.
Right now, the U.S. is the single largest donor to global health in the world, pouring more than $10 billion this past fiscal year into international health efforts. While that number represents less than 1% of the total U.S. spending, millions of people worldwide are directly impacted by it. The money supports a vast range of efforts, from a million mpox vaccines shipped to the Democratic Republic of the Congo to monitoring for influenza in Chile.
While there are unknowns – for example, Trump has not yet named a nominee to run the U.S. Agency for International Development – his previous administration and pre-inaugural statements offer clear indications on where he stands.
Changes are expected — but not immediately, perhaps. Even an executive order or policy statement on day one takes time to implement. "It's not like magic, like wave the presidential pen and then everything has changed," says Elisha Dunn-Georgiou, president and CEO of the Global Health Council, a nonpartisan group that advocates for global health.
Here are four of the top issues that global health specialists are watching and what they think could happen.
Will the U.S. leave the World Health Organization?
In April 2020, with the COVID pandemic raging, Trump halted U.S. funding to the World Health Organization. In July of that year, he officially started the process of withdrawing the U.S. from the international organization.
The WHO is the United Nations agency focused on global health. It works all over the world monitoring health threats, evaluating news vaccines and medications, coordinating health responses to emerging crises as well as ongoing issues and providing expert support particularly when a country or region is facing a health emergencies, among other things.
Trump was not happy with WHO's response to COVID, accusing the group of being slow to act. At the time, he also said, the WHO caved to pressure from China "to mislead the world when the virus was first discovered by Chinese authorities" and that the organization was under the "total control" of China.
The potential loss of U.S. funds would have been hugely significant: The U.S. is the single biggest donor to WHO, giving $1.284 billion during the 2022 and 2023 and beating Germany, the second place donor, by hundreds of millions of dollars.
However, ties between the U.S. and WHO were never formally severed because the U.S., according to the terms of its membership, has to give a year's notice to withdraw. President Biden took office well before that one-year mark and immediately reversed course.
In the run-up to the 2024 presidential campaigns, Trump has reiterated the threat to withdraw from the WHO.
What might happen in 2025
Some Washington insiders are expecting Trump to announce plans to withdraw from the WHO on day one in office (or at least start the process since there's still that one-year notice period). His dislike for the international body lingers from the height of COVID pandemic, and he continues to argue the organization is controlled by China.
This withdrawal would not be a first in the WHO's history. In 1949, during the Cold War era, the Soviet Union sent a withdrawal notice by telegram. They argued that the U.S. dominated the organization and that Eastern Europe had not received adequate medical resources. This resignation was followed by others, including Hungary, Poland, Romania and Ukraine. They have since rejoined.
The thought of a U.S. withdrawal worries Elisha Dunn-Georgio, head of the Global Health Council.
"It would be really bad for the U.S. to withdraw, in terms of … access to data, to surveillance, to being at the table negotiating and holding other countries accountable when there is an epidemic or pandemic," she says. "And if the U.S. steps out, other countries with a lot of power – China, Russia, other powers that want to shape the WHO – would take that opportunity to do so."
A WHO spokesperson declined to comment on the possibility of the U.S. withdrawing, saying, "as a government in transition, they need the time and space to make their own decisions."
Experts say there's another possible scenario: Trump could threaten to pull out unless WHO changes the way it operates.
Max Primorac, the Heritage Foundation researcher, wrote in Project 2025 that the U.S. government must ensure "a higher level of financial and programmatic accountability [at the WHO and elsewhere], including assurances that language promoting abortion will be removed from U.N. documents, policy statements, and technical literature."
He also wrote that the U.S. should have "more prominent representation" on technical committees and committees that set regulations to ensure U.S. resources are spent appropriately, aligned with American values and protect U.S. health-related innovation.
Though the Project 2025 plan was assembled by a network of Trump's allies and advisers, it is not clear if he supports its proposals.
Trump has called on the world to abolish WHO and replace it. "I will work to forge a new coalition of nations that are strongly committed to protecting health while also upholding sovereignty and freedom," he said in an Instagram post from 2023. However, there have been no details about what that new coalition might look like, says Dunn-Georgio.
Will Trump reinstate – and expand – the Mexico City policy?
That's the name of the rule first implemented by Ronald Reagan in 1984 at a U.N. conference in Mexico City. The original purpose was to curtail abortion services by withholding U.S. aid to family planning groups in other countries that offer abortion services, counsel patients on abortion as an option or advocate for laws that support abortion.
During his first term Trump reinstated the Mexico City Policy just three days after his inauguration. That's part of a longstanding pattern: Newly inaugurated Democratic presidents revoke it and newly inaugurated Republican presidents bring it back.
The Trump administration broadened the policy to apply not just to grants for family planning but to billions of dollars in global health assistance given to groups that offer everything from malaria prevention to HIV treatment.
"So it would hardly be surprising to see a reinstitution of the Mexico City Policy," says Brett Schaefer, a research fellow at the Heritage Foundation.
Why it's controversial
Supporters of the rule say its aim is to encourage health care providers in lower resource countries to provide alternatives to abortion — for example, education on family planning and maternal care during pregnancy.
"It prioritizes what developing countries actually need, which is real development assistance, not the promotion of coercive or controversial agendas," says Elyssa Koren, the legal communications director for ADF International, an advocacy group that opposes abortion rights.
"This policy doesn't restrict [non-governmental organizations] from providing essential health services like maternal and child health care, and also from focusing on the alleviation of poverty, which we know is a primary driving factor for these really devastating maternal mortality statistics and child mortality statistics," she says.
Max Primorac, a senior research fellow in the Margaret Thatcher Center for Freedom at the conservative Heritage Foundation, wrote in Project 2025 — a policy proposal document prepared in preparation for a second Trump presidency — that the U.S. Agency for International Development's "priority of funding the global abortion industry negates programs that promote life, women's health, and the family."
Groups that advocate for abortion rights have a different perspective. They call the Mexico City Policy the "global gag rule," because it "silences what organizations can even say about abortion in their own countries," says Elizabeth Sully, principal research scientist at the Guttmacher Institute, a research organization that supports abortion rights.
Because of the possibility that a group will lose U.S. funding if they even discuss abortion services, the policy has a "chilling effect," says Linnea Zimmerman, associate professor at Johns Hopkins University who studies family planning and women's reproductive health. Facing a loss of funding, some groups could restrict care more than necessary to make sure they're aligned with the policy's rules, says Zimmerman.
"Providers themselves may be afraid to counsel, and so it really results in an overall lowering of just the general availability of services," Zimmerman says. "People are very concerned about stepping over the line and losing the funding that they may have for other health programs."
One analysis from the medical journal The Lancet in 2019 looked at abortion rates in sub-Saharan Africa across three presidencies: Bill Clinton, George W. Bush and Barack Obama. The analysis suggests the implementation of the Mexico City policy caused a reduction in access to contraception and a consequent rise in unwanted pregnancies, increasing abortion rates as much as 40% in sub-Saharan Africa.
What might happen in 2025
Given the early reenactment — and expansion — of the policy in 2017, analysts expect a quick reinstatement.
"I think it's all but certain that a Trump administration would reinstate the global gag rule and expand it," says Lawrence Gostin, director of the WHO Center on Global Health Law and professor of global health at Georgetown University. "And I expect this to happen, if not on day one, in week one of the administration."
Some researchers think that Trump will expand the policy even further, applying it to other health-related programs funded by the U.S..
Indeed, in Project 2025, Primorac calls for an extension of the policy to "all foreign assistance."
What will happen to PEPFAR?
The HIV epidemic is still in force — and the President's Emergency Plan for AIDS Relief, or PEPFAR, is a major player in supporting prevention and treatment. It was started in 2003 under President George W. Bush and it's huge.
The U.S. has poured more than $100 billion dollars into PEPFAR — last year, more than $6 billion was allocated to the program, for example. That makes it "the largest commitment by any nation to address a single disease in history — saving 26 million lives, preventing millions of HIV infections," according to the U.S. State Department, which oversees the program.
Today, millions of people around the world depend on the program, including not just those on daily medications paid for by PEPFAR but also 7 million AIDS orphans whose basic needs — from schooling to food and clothing – are covered.
The first Trump Administration proposed cutting PEPFAR's budget by nearly a billion dollars — a little less than a quarter of its budget back then — with the goal of streamlining the program and focusing on about a dozen countries that were close to controlling the disease.
Congress rejected those cuts. And, for a long time, PEPFAR enjoyed broad bipartisan support.
But no more. Eric Goosby, the second director of PEPFAR from 2009 to 2014 and now a professor of medicine at University of California, San Francisco, says support has frayed as a new generation of Republicans have been elected to Congress.
"The turnover is complete. There's no one who has a memory of PEPFAR — what it did, what it is doing — [no newly elected Republican] really has a Republican warm spot in their heart for it because it was set up by President Bush," Goosby says. Usually, the program is reauthorized for five years but, in 2024, it was only reauthorized for one year. The tension around reauthorization arose as a coalition of anti-abortion groups raised concerns about how the funds are used (even though there is already a law banning the use of U.S. foreign aid for abortion.)
It's unclear exactly how Trump will engage with the program this term but many are predicting cuts. "It could either be fully defunded, or it could be defunded incrementally," says Javier Guzman, director of the global health policy program at the Center for Global Development.
The prospect of defunding the program "that's really what keeps me up at night, more than almost any other issue," says Nina Schwalbe, who heads the global health think tank Spark Street Advisors, pointing to the millions of people who depend on the program for medical care, medications and support.
Critics say that the program's approach is outdated and has a major failing: It does not build up the local health system. For example, researchers at the Heritage Foundation have argued for revamping the flagship program and putting a priority on transferring services to local partners rather than to large international organizations. "PEPFAR should be redesigned to transition it toward more country ownership and co-financing," wrote Tim Meisburger, when he was a visiting fellow at the Heritage Foundation.
Similarly, Project 2025 praises PEPFAR's past localization efforts. "During the [first] Trump Administration, PEPFAR increased the share of funding to local entities from about 20% to nearly 70% …. The next Administration should extend that localization model to all global health," Primorac writes.
Will the U.S. leave the Pandemic Treaty negotiations?
Over the past two years, 194 countries have been busy negotiating a pandemic treaty. The agreement would lay out how information and resources will be shared if and when the next pandemic strikes, among other things.
The idea for a global pandemic agreement was born after Trump's first term. In 2021, a group of world leaders called for an international agreement that dictates how counties cooperate to avoid and address pandemics when they happen. They were motivated by the failures of the global response to COVID-19. Many low- and middle-income countries felt they had shared critical information about the virus but didn't get vaccines, masks, oxygen and other needed items in exchange.
So far, the countries have been unable to agree on the details. The U.S. has been playing a key role in pushing negotiations along, says Lawrence Gostin, a professor of global health law at Georgetown University. "The United States has really been the glue," he says. "They're the one trusted agent, both in Africa and also in the European Union."
Trump seems poised to take a different approach.
Why it's controversial
Trump has spoken out against the negotiations, including in an Instagram post from 2023, saying any pandemic treaty would be "immediately terminated" in his second administration and that the draft treaty would "surrender American sovereignty to the World Health Organization, again controlled by China." WHO would not actually be a party to the agreement; however, it is convening the negotiations. "I would not allow public health to be used as a pretext to advance the march of global government," Trump added.
A number of Republicans have voiced other concerns, including the worry that a treaty could threaten U.S. intellectual property rights by requiring pharmaceutical companies to share their proprietary information about potential treatments in the event of a health emergency.
"The pandemic agreement has gotten woefully off-track," says Schaefer of the Heritage Foundation. Instead of focusing on what we know went wrong with the COVID response, he says, the negotiators are now debating issues that did not contribute to COVID's original spread.
He points out that in the first few years of the Trump administration, the U.S. was cooperative and involved in WHO and "that did not prevent the COVID-19 pandemic" and that China "suffered no ramifications or consequences" for agreeing to share pandemic information but then failing to do so.
Prompted by concerns from Trump and American voices, negotiators have added language to their draft explaining that the treaty would not impinge on a country's sovereignty or provide WHO any authority over domestic policies. Still, that narrative has persisted. "I've never seen that before, actually. All around the world there is something like a coordinated attempt for misinformation in an attempt to frustrate this process," Roland Driece, one of the two co-chairs of the negotiations and the director for international cooperation at the Ministry of Health in the Netherlands, told NPR in May 2024.
What might happen in 2025
For those who have been working for a pandemic treaty, the Trump Administration is seen as a looming threat. That's because the negotiations are done by consensus, so even one dissenting voice among the 194 nations can derail the process.
The question: How active will the administration be in opposing the treaty?
"A best case scenario is [Trump's representatives] don't show up and they let the other member states get on with the business, and a worst case scenario is that they're there actively trying to ruin the process," says Schwalbe, a strong proponent of a pandemic treaty.
Gostin, of Georgetown University, worries Trump will "torpedo" the treaty and that will leave "all of the gaping holes in preparedness and equity, in vaccines, in personal protective equipment, you name it," he says. "It means that we're no better off — and we're probably a lot worse off — because we've unraveled international cooperation."
Schaefer of the Heritage Foundation counters. "There's hardly a lack of precedent for maybe addressing pandemic issues outside of the WHO, if that's indeed where the Trump administration is intent on going," he says. "There's a reason why UNAIDS exists, and there's a reason why GAVI [The Vaccine Alliance] exists, and there's a reason why the Global Fund exists — and that's because the WHO has, in the past, not been seen as either the most effective or the most responsive vehicle for addressing various international health concerns."
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