“What’s going on?” That’s a line from 4 Non Blondes’ massive hit song, “What’s up?” which has been stuck in my head since yesterday.
Just 10 days after taking office, U.S. President Donald Trump initiated U.S. withdrawal from the Paris Agreement and the World Health Organization, reimposed a policy banning funding to foreign organizations that provide abortion care even if those services use non-U.S. funds, and rejoined an international declaration that purports to support women’s rights — but not their right to abortion.
However, the biggest surprise — and one that has sparked concern and confusion in the global health community — is Trump’s 90-day pause on U.S. foreign aid, and the stop-work order that came after, which immediately halts almost all U.S. aid-funded programs globally. One of the most immediate concerns is its impact on people living with HIV, especially those who require continued access to antiretroviral treatments. As soon as the stop-work orders reached their inboxes, organizations doing lifesaving HIV and AIDS work, funded by PEPFAR, couldn’t do much but comply.
That was the case for the Infectious Diseases Institute in Kampala, Uganda. They pulled out employees from districts where they support local officials providing services to 200,000 people living with HIV, and had to shut down a program assisting the country’s national tuberculosis response, my colleague Andrew Green reports.
The U.S. State Department issued a memo Tuesday placing exemptions for lifesaving humanitarian assistance, including “core life-saving medicine, medical services, food, shelter and subsistence assistance, as well as supplies and reasonable administrative costs necessary to deliver such assistance.”
However, its lack of details only raised more questions: Does that include HIV and tuberculosis drugs, for example?
Josh Michaud, associate director for global health policy at KFF, which has been tracking Trump’s global health orders, tells me the White House and State Department “have not been entirely clear on the definitions being used for which programs fall under the waiver,” creating room for interpretation.
If lifesaving programs are exempt, “the question is: Is PEPFAR one of those? One would think so but not totally clear,” he says.
Even PEPFAR itself is unsure about the implications, multiple sources tell my colleague Adva Saldinger.
Some believe the waivers include HIV treatments disbursed by PEPFAR, as well as TB medications. However, some organizations tell Devex they are continuing the pause in services, awaiting clear guidance from the U.S.
The risk, of course, is that any prolonged treatment interruption may lead to viral rebound or drug resistance in individual clients. More broadly, there are concerns that pausing services without warning will erode the trust that has been built over decades, Andrew tells me.
Adva has written a helpful guide on how waivers work — requests must be submitted by 3 p.m. daily — and what implementers should do in this most ambiguous moment.
Read: Questions swirl about whether humanitarian aid waiver applies to PEPFAR
More on this: Confusion, fear as PEPFAR partners suspend HIV services
+ We have an upcoming event with Mark Dybul, former head of PEPFAR and the Global Fund, who will discuss the changing nature of global health politics and why the present moment could be an opportunity for total reinvention of the system. This event is on Feb. 5. For more information, watch this space.
Down the drain?
The bottom line, however, is that abruptly stopping U.S. foreign aid will have significant global health implications, and it could destroy the infrastructure the U.S. government has helped build for decades. Dr. Atul Gawande, who ran USAID’s global health programming for the last three years, tells my colleague Sara Jerving. “I don’t even know how to put it in words," he says.
Here’s what’s at stake: With the aid freeze and work stoppage, Trump left many USAID contractors without work. Many were also laid off, some without severance pay. Gawande says many of these people do lifesaving work and are now “being thrown away like they’re nothing.” This talented team of people will look for work elsewhere, he says.
The U.S. is the largest donor to HIV and AIDS programs worldwide, and its investments, via PEPFAR, over the past two decades have helped save lives. But the stop-work order threatens to undermine those investments, and they can’t be salvaged by a few exemptions.
USAID also plays a critical role in preventing deadly outbreaks. For example, it has cooperative agreements with different countries monitoring emerging outbreaks. In the past few years, it also helped build capacities in several countries to detect and report on pathogens that could potentially cause an outbreak. Stopping that work can leave the U.S. vulnerable and blind to these emerging threats. Cases in point: Ebola has been confirmed in Uganda and is potentially emerging in the Democratic Republic of Congo. This comes alongside the Marburg outbreak in Tanzania and the ongoing spread of mpox across the continent.
Read: Stop-work destroys USAID global health infrastructure, Atul Gawande says
Going, going, gone
Another Trump decision subject to interpretation is his executive order to withdraw from WHO.
It will no doubt have huge implications for WHO, but many questions remain such as “What’s the timeline here?” and “Is this even legal?”
I asked Lawrence Gostin, founding O'Neill chair in global health law at Georgetown University, to help make sense of all these ambiguities, including whether the EO effectively withdraws the U.S. from the amendments to the International Health Regulations — ironically the U.S. pushed for these to be agreed upon at last year’s World Health Assembly.
We came to one conclusion: “Trump might be saying, ‘Well, I'm going to give notice of our intention to withdraw.’ But for all intents and purposes, he has withdrawn. He's basically rescinded adoption of the IHR amendments, pulled us out of pandemic agreement negotiations, froze all of U.S. funding, and recalled U.S. staff. That sounds to me like he's withdrawn already,” Gostin says.
Read: Trump's executive order on WHO, explained (Pro)
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WHO else?
Here’s another thing that experts are scratching their heads about.
In his executive order withdrawing the United States from WHO, Trump indicated that other domestic and international partners should take over the agency’s “necessary activities.”
He didn’t spell out what those activities included and who could take over, so Andrew asked experts in the field. But as they considered exactly what WHO does, they had trouble identifying any organization in a position to take on what they considered its key responsibilities.
WHO was established in 1948 to fill gaps in global efforts to coordinate health responses and to push toward greater equity and health care for all. It has a convening power that is somewhat singular and is uniquely positioned to gather data and information on disease outbreaks that are as vital to people in the U.S. as anywhere else.
So while partners might be able to take over some WHO tasks — some emergency response efforts or creating safety guidelines — the U.S. may soon find that much of what the agency does is — surprise! — not so easy to replicate.
Read: Can the US replace the World Health Organization?
That’s what he said
Trump isn’t the only one bewildering global health folks. Robert Kennedy Jr., Trump’s nominee for the top U.S. health official post, also had senators questioning what his actual position is on vaccines and abortion — contentious issues that divide many in the U.S. and abroad.
During his confirmation hearing before the U.S. Senate Finance Committee on Wednesday, RFK Jr. dismissed accusations that he is anti-vaccines, arguing instead that he is “pro-safety.” He said he believes “that vaccines play a critical role in health care,” and all of his kids are vaccinated.
RFK Jr. also said “every abortion is a tragedy” and “states should control abortion” — a statement that goes against what he said on the campaign trail when he was running for president. A placard during the hearing quoted RFK Jr.: “I’m pro-choice. … I don’t think the government has any business telling people what they can or cannot do with their body.”
But the Health and Human Services nominee said Trump wants to end federal funding for abortions in the U.S. and abroad, and that he will serve “at the pleasure of the President.”
Democratic senators came to the hearing with receipts — quoting the many claims RFK Jr. made over the years on vaccines and science, including that vaccines cause autism, COVID-19 targeted Blacks and Caucasians but that Ashkenazi Jews and Chinese people are immune from it, and that Lyme disease is a “highly likely,” military engineered bioweapon — the latter he said he “probably did say.”
But RFK Jr. was clear about his goals to tackle chronic diseases, though he said he won’t take food away from anybody, including his boss who he said loves Diet Coke. He also said that he “absolutely support[s] PEPFAR” and that he will “happily work” with lawmakers to strengthen the program. That’s one receipt global health folks should be keeping in the next four years.
Read: RFK Jr. takes a lot of heat during first confirmation hearing
What we’re reading
Kansas City is currently experiencing a TB outbreak with 67 active cases. [Reuters]
Guinea eliminates the gambiense form of human African trypanosomiasis, or sleeping sickness, as a public health problem. [WHO]
A drone strike kills at least 70 people in a hospital in Sudan’s North Darfur state. [CNN]
About the author
Jenny Lei Ravelo@JennyLeiRavelo
Jenny Lei Ravelo is a Devex Senior Reporter based in Manila. She covers global health, with a particular focus on the World Health Organization, and other development and humanitarian aid trends in Asia Pacific. Prior to Devex, she wrote for ABS-CBN, one of the largest broadcasting networks in the Philippines, and was a copy editor for various international scientific journals. She received her journalism degree from the University of Santo Tomas.
