One year ago today (20 January), the Trump administration exploded the global health sector by immediately “pausing” all aid for 90 days – and dispensing with 83% of US Agency for International Development (USAID) projects six weeks later.

Trillionaire Elon Musk and his Department of Government Efficiency (DOGE) “chainsawed” at USAID projects and contracts, folding the fractured remains of the agency that once saved millions of lives into the US State Department, which has little expertise to manage global health projects.

US Secretary of State Marco Rubio and Musk claimed that life-saving projects were exempted from the waiver, but this is simply not true.

The US President’s Emergency Plan for AIDS Relief (PEPFAR) supported some 20 million people on antiretroviral medicine.

After the “pause” was announced, HIV clinics across sub-Saharan Africa were issued with immediate “work stop” letters and closed within days as they had no money to pay staff, cutting people off from access to antiretroviral medicine. 

Dr Tedros Adhanom Ghebreyesus, the World Health Organization (WHO) Director General, described the US actions as the “greatest disruption to global health finance in memory”, “sowing chaos”, threatening to roll back decades of progress on infectious and neglected diseases.

Death tracker

To date, 757,314 people – the majority children – have died from the funding cuts, according to ImpactCounter, which tracks the effect of USAID cuts via sophisticated modelling tools. That is 88 deaths every hour.

Modelling the effect of the 90-day pause on HIV in sub-Saharan Africa, ImpactCounter estimates that 159,000 adults may have died in that region alone as a result of the suspension of aid by USAID and PEPFAR. 

There are also almost a million more malaria cases, over 700,000 affecting children, due to aid cuts.

What was also untrue was Musk’s claim that DOGE had saved the US government $1trillion by last October. 

Of DOGE’s published list of cancelled contracts and grants, the 13 biggest were all incorrect, according to the New York Times. The top two were Defence Department contracts worth $7.9 billion that have not been terminated.

WHO withdrawal

One year ago, Trump also withdrew the US from the World Health Organization (WHO). To date, the US has failed to pay millions in membership fee arrears, breaking an agreement it struck with the WHO back in 1948.

In 2023, the US contributed around a quarter of WHO’s budget in both assessed (mandatory membership fees) and voluntary contributions. Thus, its withdrawal severely disrupted the work of the WHO, which had to spend the past year whittling away at staff and programmes to make ends meet. It is still 25% short of the 2025/26 budget.

As WHO Director General Dr Tedros Adhanom Ghebreyesus has said several times, it is a country’s right to stop funding organisations and programmes, but this needs to be done in a “planned and orderly way” to minimise service disruptions.

The US withdrawal from WHO also meant that the Global Polio Eradication Initiative no longer had access to the US Centers for Disease Control (CDC) specialised polio laboratory, and had to find other labs to test for polio.

In addition, the US pulled its support for UNAIDS, which lost almost 80% of its project funding.

The Heritage Foundation, which authored Project 2025, the governance blueprint being followed by the Trump administration, asserted in 2023 that HIV/AIDS is “primarily a lifestyle disease”,  “except in cases of rape or maternal transmission”.

This appears to be informing the position of the Trump administration, as it has shifted its approach to HIV to focus on mothers and babies.

‘America First’ Global Health Strategy

Last September, the US State Department published its America First Global Health Strategy to replace PEPFAR and USAID. The strategy is focused on making “America safer, stronger, and more prosperous” via bilateral memorandums of understanding (MOUs) with previous aid recipients.

At around that time, the US State Department also extended “bridging finance” to some PEPFAR recipients who had been left in crisis for eight months following the aid freeze and subsequent closure of USAID.

These MOUs make health aid contingent on recipient countries agreeing to provide the US with rapid access to information about any “novel and emerging infectious diseases with epidemic or pandemic potential”. This is a direct challenge to the WHO’s Pandemic Agreement, the final piece of which – about pathogen access and benefit-sharing – is currently being negotiated in Geneva.

So far, 15 MOUs have been signed with African countries – the latest being with Malawi on 14 January. Several have been concluded alongside trade deals, while others – including with Zambia and the Democratic Republic of Congo (DRC) – have been delayed until the US gets more favourable access to their minerals.

The agreements provide opportunities for US companies to provide logistics, data, and supply-chain support.

The MOUs are the precursor to five-year grants that involve a rapid transfer of responsibility for domestic health programmes from the US to donor countries from year two of the agreement. However, part of the responsibility countries will have to shoulder is a large network of epidemiologists, data capturers and laboratories to meet the US demand for rapid information about pathogens.

Non-governmental organisations (NGOs) that were previously key to community outreach and service provision are not mentioned in the MOUs, and the most recent agreement with Malawi notes that the MOU “marks a critical shift away from parallel NGO delivery systems and the healthcare workforce structures they created, restoring responsibility for those resources to the national government”.

However, in the MOUs with Nigeria and Uganda, Christian organisations delivering health services are specifically mentioned as key to the agreements.

The MOUs have been concluded in haste, with vague disease targets, as countries’ PEPFAR bridging finance runs out on 31 March, and the new MOUs are supposed to kick in on 1 April.

While many African countries, in particular, will struggle to take full responsibility for health service delivery, the withdrawal of US assistance has seen a renewed call from several African leaders to move away from aid dependency.

On average, African Health Ministers only have $40 per capita for health expenditure and only two countries reached a goal set in 2001 for countries to spend 15% of their GDP on health.

Several African initiatives have developed from the aid crisis, starting with a High-Level Health Financing Conference in Addis Ababa last February, hosted by Rwandan President Paul Kagame, the African Union’s (AU) Champion on Domestic Health Financing. This discussed alternative domestic sources of health funding, and has since resulted in a ministerial group on this issue.

In March, Africa CDC launched a new financing guide for member states, which will focus on “updating national health financing plans in 30 countries, piloting innovative revenue mechanisms, and launching transparency dashboards”.

In parallel, Wellcome Trust hosted a series of regional meetings and papers on global health reform, which moves away from aid dependence to “a sustainable and equitable global health system that supports a healthier future for everyone”.

Image Credits: Reuters Youtube.