One year after the United States announced its withdrawal from the World Health Organization, a former WHO Headquarters Staff Association President reflects on how presence, governance, and leadership shape influence in global health.

In January 2024, I stood before the WHO’s Executive Board, chaired by Qatar’s Minister of Health, Dr. Hanan Mohammed Al Kuwari. I was speaking as an elected staff member representing more than 10,000 staff across the WHO and its partner agencies. When I opened my remarks by honoring a colleague killed in Gaza, the room, filled with health delegates from 194 member states, fell silent. Across political lines, delegates expressed empathy.

That moment reminded me that global health cooperation does not run on treaties or budgets alone. It is held together by trust, the fragile belief that even adversaries can remain in the same room long enough to cooperate on what keeps people alive.

I did not set out to work in global health. I began my career at a New York investment bank. During the pandemic, I helped lead launch preparations for a COVID-19 therapeutic and saw American leadership at its best through Operation Warp Speed.

I joined the WHO to work on vaccine supply equity so that, in the next pandemic, access and supply chains don’t break along geopolitical lines.  I eventually reported to a senior Chinese official who had risen through the ranks at headquarters. We were supposed to be adversaries. My Taiwanese heritage and American upbringing placed me in a rivalry I did not choose. Yet she treated me with professionalism and fairness. Over time, we built trust and found common ground on expanding access to essential medicines.  But trust is only half the equation. The other half is presence.

America pays, others decide

The United States has historically been the WHO’s largest funder contributing roughly 18% to the annual budget through a combination of assessed fees and voluntary donations. Yet Americans are chronically underrepresented in the professional workforce. 

According to the latest workforce data to be presented at the 158th session of the Executive Board in early February, U.S. citizens continue to hold roughly 7% of professional positions.  The European region holds about one in three professional posts, more than four times America’s representation. This influence gap runs to the top. No American has ever served as Director-General. For years, Washington has tried to influence the organization from outside through press releases and funding threats. In these institutions, indignation is noise. Seats are power.

I learned this first hand when headquarters staff elected me President of the Staff Association of WHO’s headquarters, representing about 3000 staff in Geneva as well as HQ-managed offices in Japan, New York City, Budapest, Lyon, Berlin and Tunis. It was a role that put me regularly in the room with Director-General Tedros Adhanom Ghebreyesus and senior leadership. Institutions like the WHO rarely change because they are denounced from afar. They change because people stay in the process long enough to turn criticism into votes, rules and resolutions.

Downsizing Is Not Accountability

None of this requires romanticizing the WHO.

It is a glacial bureaucracy. Last year, leadership launched one of the largest downsizings in its history, announcing plans to cut roughly a quarter of the workforce by June 2026, in a massive restructuring exercise. But making an institution smaller is not the same as making it accountable. Thousands of front-line staff were terminated while a shadow workforce of consultants remained. This narrowed a roughly $1.7 billion funding gap without changing how power is exercised or decisions are made and enforced.

The finality of the US decision, and its inevitable budget impacts, began to permeate in December 2024, shortly after the US Presidential elections.

On 17 December WHO leadership gathered in Lyon, France, with President Emmanuel Macron for the opening of the new WHO Academy. The setting was elegant. It felt like a toast raised on the proverbial cruise ship deck while someone, somewhere, had already spotted  the iceberg. Yet the music played on.

In the afternoon session, the mood shifted.  Dr. Tedros paused and said quietly, “Let’s give them a peaceful holiday.” Shortly afterward, WHO staff were told they would receive two additional days of leave. It was a kind gesture, and also a telling one. The calm before the storm. By then, those of us who had been in Lyon knew the die was already cast – the US would withdraw on Day 1 or Day 2 of President-elect Donald Trump’s second term in the White House.  On Inauguration day, 20 January 2025, the announcement was made.

Navigating the Rupture: Beijing’s Opportunity in America’s Absence

The United States withdraws largely alone. Except for Argentina,  every other WHO member state has chosen to remain. And in fact, for historical reasons there is no real legal provision allowing WHO member states to withdraw, with the exception of the United States. 

With the next Director-General election approaching in 2027, leadership choices and reform priorities are being shaped by those still present. The question is whether American absence makes China’s influence easier, or harder, to counter.

We have seen this before. In 2019, China ran a disciplined campaign to win the top job at the United Nations Food and Agriculture Organization (FAO). U.S. officials were caught off guard. “It made us look like complete fools,” one State Department official was later quoted as saying. This is not about relitigating 2019. It is about not repeating the same mistake.

In May 2025, Beijing arrived at the World Health Assembly with about 180 officials, according to press and delegate accounts, and announced a $500 million pledge to the organization. Washington sent no delegation. Taiwan was again blocked by WHA member states from being granted observer status, this time without visible resistance.

Winning the 2027 Director-General election is an even bigger strategic prize. The organization that sets global health standards and coordinates pandemic response is an asset Beijing will pursue with patience. The groundwork is being laid now, while the United States steps away.

Reform Requires Presence

So who wins when America leaves? It is a Catch-22.

US Secretary of State Marco Rubio and Secretary of Health and Human Services Robert F Kennedy Jr have been clear that the United States should no longer write blank checks to international bureaucracies that lack accountability. 

As Rubio recently put it, “sometimes true leadership means knowing when to walk away.” Demanding results is not retreat. It is a leadership responsibility, some critics of continued engagement might say.

They raise a fair point. Staying only works if reform and cooperation are possible. 

But in global health, they are – if and only if U.S. leadership is present. Allies do not follow a country that leaves the room. They follow one that shows up with a plan. The world is not waiting for us. It is waiting for someone to lead.

What Re-engagement Would Require

If Washington really wants a more effective and accountable WHO, the pathway to getting that is clear and concrete.

Reengage with conditions tied to transparency and governance. Align representation with contribution by rebuilding the American professional pipeline. Place American experts where technical norms and standards are written.

Demand enforceable oversight, not cosmetic restructuring. Work with our allies on the Executive Board to advance a serious reform agenda. Reinvigorate WHO’s technical expertise as a truly merit-based organization that recruits and hires the most qualified staff at all levels transparently and internationally – and not through fixed appointments, political favoritism, or over-reliance on consultants who just happen to be living in relatively close proximity to Geneva. Deliver a genuine reset, not just headlines.

Make WHO great again.

The Way Forward: Leadership is a Choice

Today, the American flag no longer flies at WHO headquarters. That absence is visible to every delegation, every staff member, and every government navigating the institution that remains.

The Pandemic Agreement is moving forward, and the campaign to elect a new WHO Director-General in 2027, when Tedros’ second term ends, is already underway. WHO will evolve with or without the United States. Even Dr. Tedros has described U.S. withdrawal as a “lose-lose.” On that point, he is right.

America First cannot mean America absent. While our stars and stripes have come down, the threats to our health, security, and sovereignty have only gone up. I remain hopeful that one day our flag can fly again over an institution worthy of American taxpayers’ support and the American people’s trust. Leadership has always been a choice, and we the American people can make it again: to lead as one Nation, indivisible, with peace, strength, and the accountability our citizens deserve.

Christina Liu served at WHO from 2022 to 2025 as a technical officer on vaccines and access to medicines. She was the President of WHO Headquarters Staff Association from 2024-2025.

A US citizen and native of California, she is currently a Board Advisor for Global Public Health at BioLiterate.  She has over 18 years of experience spanning global health, international policy and in the pharmaceutical industry, including with Roche and Novartis. Liu holds a dual Masters in Biomedical Science/MBA from The Wharton School and the University of Pennsylvania.  

Image Credits: Anonymous/HPW, Christina Liu, WHO, WHO/Pierre Albo .