The United States has moved at speed to secure several new bilateral health Memoranda of Understanding (MOUs) in the past week, including, for the first time, four in Latin America – with the Dominican Republic, El Salvador, Guatemala and Panama.

To date (2 March), the US has signed 24 bilateral health MOUs in terms of the Trump administration’s America First Global Health Strategy.

Announcing its agreement with Panama, the first MOU within Latin America, the US State Department described it as “strengthening Western hemisphere health security”, which it added is “a priority”.

The four Latin American agreements involve smaller grants and are almost wholly focused on disease surveillance.

The other 20 bilateral agreements are all with African countries – mostly previous recipients of health grants via the now disbanded US Agency for International Development (USAID) and decimated US President’s Emergency Fund for AIDS Relief (PEPFAR).

Several of these countries are facing dire shortages of medicines for HIV, tuberculosis, and maternal and child health as a result of the US withdrawal of funds.

The five-year MOUs are aimed at rapidly transferring financial responsibility for these key health services to countries themselves – as some, such as Kenya, Uganda and the Democratic Republic of Congo (DRC) – derived over half their HIV budgets from donors, particularly the US. In the DRC, for example, at least half the antiretroviral medication it used was covered by the US.

High parting price

However, the parting price for these transitional MOUs includes extensive investment in infectious disease surveillance networks. The aim is to supply the US with pathogen information within a week of any outbreak to not only “keep America safe” but to give US firms exclusive access to pathogen information, which will enable them to make vaccines, medicines and diagnostics to combat these.

The US-DRC MOU, signed on 26 February, focuses extensively on “strengthening the DRC’s capacity to detect and contain infectious disease outbreaks before they spread internationally”, according to a US State Department statement.

The DRC has experienced recent Ebola outbreaks and, for the past year, the biggest mpox outbreak in the world.

According to the MOU, the US commits to investing up to $900 million over five years and the DRC commits to increasing its health expenditure by $300 million.

The bulk of the money will go into “a national integrated surveillance and outbreak response system, including a high-quality laboratory network capable of detecting and investigating infectious disease outbreaks within seven days”. 

“Under this system, relevant authorities, including the United States and other partners, will coordinate epidemic preparedness and rapid response measures to contain outbreaks and prevent their spread to neighboring areas,” according to the statement.

The MOU also aims to modernise data and disease surveillance systems with “enhanced electronic medical records and interoperable platforms”, professionalise community health workers and “expand integrated delivery of essential health services for HIV, tuberculosis, malaria, polio, and maternal and child health”. 

First, the minerals…

The US held off signing an MOU with the DRC in terms of its “America First Global Health Strategy” on 5 December, when it signed deals with Rwanda and Kenya on the sidelines of the signing of a peace accord between Rwanda and the DRC.

Instead, the US and the DRC signed a “strategic partnership agreement” to  “promote secure, reliable, and mutually beneficial critical mineral flows for commercial and defense purposes”. 

The DRC is one of the world’s most important sources of rare earth minerals, but China has dominated the purchasing and processing of its minerals. In the past two months, the DRC has opened its rare minerals supply to the US.

In late January, the DRC sent the US a shortlist of state-owned assets involving manganese, copper, cobalt, gold and lithium, for US investors to consider as part of a minerals partnership, Reuters reports.

Meanwhile, the US MOU with Guinea, signed on 27 February, was also preceded by a minerals MOU, signed with the US on 5 February, giving the US access to “critical minerals”.

The health MOU prioritises strengthening the country’s “laboratory networks with biosafety and biosecurity management aligned with international standards by 2027”.

Legal backlash in DRC

But not all countries want to exchange their minerals and other assets for aid.

A group of lawyers in the DRC are challenging the minerals MOU in their Constitutional Court, arguing that it violates the country’s Constitution in various ways, including undermining national sovereignty over natural resources.

“By filing this case with the Constitutional Court, we are assuming our responsibility as Congolese citizens to protect the sovereignty of our country and safeguard our patrimony for future generations,” said attorney Jean-Marie Kalonji, one of the plaintiffs. The case has yet to be heard.

Meanwhile, Zimbabwe recently backed out of talks with the US as it was unhappy with what the US required from it in terms of outbreaks.

“Zimbabwe was being asked to share its biological resources and data over an extended period, with no corresponding guarantee of access to any medical innovations—such as vaccines, diagnostics, or treatments—that might result from that shared data,” explained Nick Mangwana, Secretary for Information, Publicity and Broadcasting Services.

“In essence, our nation would provide the raw materials for scientific discovery without any assurance that the end products would be accessible to our people should a future health crisis emerge. The United States, meanwhile, was not offering reciprocal sharing of its own epidemiological data with our health authorities.”

Kenya’s MOU with the US, the first of the series, has been halted by the country’s High Court as it faces two separate court challenges for giving the US access to patient data and pathogen information.

The government of Zambia acknowledged last week that it is unhappy with part of a proposed health aid deal with the United States that “does not align with the country’s interests” and has requested “revisions” to the MOU.

The Zambia-US bilateral health deal was due to be signed last December, but it faltered after the US linked the billion-dollar deal to access to Zambian minerals, particularly copper and cobalt.

Just four days before the MOU was due to be signed, the US announced that the two countries had committed to a plan to unlock “a substantial grant package of US support in exchange for collaboration in the mining sector and clear business sector reforms that will drive economic growth and commercial investment that benefit both the United States and Zambia”.

‘Extractive’ policy

Sophie Harman, professor of international politics at Queen Mary University of London, argues in last week’s BMJ that “extraction is the core principle of US President Donald Trump’s America First global health policy”.

“The current US administration does not aim to improve health worldwide, instead it intends to make US companies richer and facilitate ‘leveraging US global health leadership to compete with China’,” argues Harman.

“Entering a deal with the US government is a potential lose-lose for states. These countries risk losing resources and opportunities for wealth creation in their own countries, threatening alliances with China for relatively small advances in health, and creating political turmoil in domestic courts.”