Devex CheckUp: What the Trump withdrawal means for WHO (and for Americans)

As anticipated, U.S. President Donald Trump started the process of withdrawing the United States from the World Health Organization on Monday — one of his first actions after taking office. It was a repeat of his first term, when he also began the process of pulling out of WHO.

His executive order also called for a pause to any additional funding for WHO and demanded that any U.S. government personnel or contractors seconded to the agency be recalled and reassigned. In another blow to the international global health sector, he also pulled out of ongoing negotiations around the pandemic accord.

Trump justified the move with accusations that the agency had fallen under inappropriate political influence from some members — likely a swipe at China — and failed to adopt reforms. He also accused WHO of demanding too much support from the United States in comparison to China, which has a larger population, even though WHO dues are determined based on gross domestic product.

WHO issued a statement Tuesday protesting that the agency has worked with the United States over the past seven years to implement “the largest set of reforms in its history, to transform our accountability, cost-effectiveness, and impact in countries.” It called for a constructive dialogue to preserve the partnership.

But what happens if Trump doesn’t change his mind, as seems likely? The U.S. provides more than 15% of the agency’s annual funds, so WHO could soon face a huge financing gap. Legally, the U.S. has to continue paying for the next 12 months until the withdrawal is complete, but there’s no guarantee that Trump will do so — or that other funders will rush in to close the gap.

It's also not clear exactly what the United States is going to do without WHO. The Centers for Disease Control and Prevention, for instance, will no longer have access to the agency’s global data, which will make its job of preventing and responding to pandemics harder. The executive order did compel Secretary of State Marco Rubio to find “credible and transparent United States and international partners” to replace WHO. Which organizations could fill the void, however, is still unclear.

Read: Trump orders US exit from WHO. Can it survive the financial hit? (Pro)

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On hold

In his flurry of executive orders, Trump also suspended all U.S. foreign assistance for 90 days to assess the efficiency of the programs being financed and to determine whether they are consistent with U.S. foreign policy. Much of the aid industry in Washington and beyond now seems to be on pause as they wait to find out how that will impact their work and their spending.

That could include the program announced by the President’s Emergency Plan for AIDS Relief, or PEPFAR, in December to reach 2 million people over three years with a groundbreaking injectable HIV prevention technology. Injected twice yearly, lenacapavir showed almost 100% efficacy in preventing HIV acquisition for participants in two crucial studies last year.

PEPFAR, in collaboration with The Global Fund to Fight AIDS, Tuberculosis and Malaria, the Gates Foundation, and the Children’s Investment Fund Foundation, had taken steps to jumpstart access to the technology, which still requires regulatory approval. And some activists are frustrated that the donors didn’t actually put forward a more ambitious plan to reach more people, given how revolutionary lenacapavir might be.

But in the wake of Trump’s order, even the initial proposal might never get off the ground.

Read: Is a new HIV prevention plan ambitious enough? And can it survive Trump?

Background reading: HIV trial shows injectable prevents 100% infection in women and girls

The fatal $4,100

PEPFAR has even bigger concerns, though, as reports emerged this week that $4,100 in program funds were used to pay the salaries of four nurses in Mozambique who provided 21 abortions over three years. Under U.S. law, no foreign funding may be spent on abortions.

Sen. James Risch, who chairs the Senate Foreign Relations Committee, has put a hold on more than $1 billion in funding for PEPFAR. And with the program up for reauthorization in March, there could be more severe consequences.

While the program’s defenders are not dismissing the incident, they point to the relatively small amount of money involved and the fact that PEPFAR’s own compliance checks caught the violation. That would seem, they argue, to indicate that the system is working as it should.

But Rep. Chris Smith, who played a role in holding up last year’s PEPFAR reauthorization over concerns that funds were being used to pay for abortions, isn’t having it. He has vowed to hold a series of hearings to investigate the program even as he — along with the rest of the world — waits to see how the Trump administration reshapes PEPFAR.

Read: Can a $4,100 mistake threaten PEPFAR’s future?

ICYMI: Sen. James Risch holding $1B in PEPFAR funding

A vision for PEPFAR

Eric Goosby has some definite ideas about just how the Trump administration might shape the program, even as he presses for the U.S. president and Congress to preserve it. In an opinion piece for Devex, the former U.S. global AIDS coordinator and PEPFAR head lays out a path toward greater country ownership of the program’s activities, which he believes is critical for achieving sustainability.

Goosby specifically calls for development partners to invest more in strengthening country-led health systems. He also wants to see more investment in an integrated health infrastructure, which might help to eliminate costly and unnecessary overlap.

Opinion: The case for PEPFAR to push for country ownership in HIV response

Disease fighters

Meanwhile, WHO emphasized its ongoing relevance this week by releasing $3 million to help battle the outbreak of Marburg disease in Tanzania, confirmed on Monday. This comes on top of the $500,000 that the agency already provided to help the country investigate suspected infections.

At least one case of Marburg, one of the deadliest pathogens to infect humans, was confirmed this week. And last week, Tanzania reported nine suspected cases and eight deaths that might be linked to the outbreak.

This is Tanzania’s second encounter with the disease in three years and officials are working quickly to try to contain it. WHO funds are helping to expedite that effort, financing the scale-up of case detection and helping establish treatment centers and a mobile laboratory.

Read: WHO releases $3 million to address Marburg outbreak in Tanzania

What we’re reading

The ceasefire in Gaza has paved the way for the delivery of hundreds of truckloads of aid to the besieged region, including critical deliveries of food aid. [Reuters]

Anthony Fauci, the infectious disease specialist who helped guide the U.S. response to COVID-19, received a preemptive pardon from former President Joe Biden to forestall potential retribution by the incoming Trump administration. [NPR]

Following alarm over a potential pandemic, officials report that after a spike of the flu-like human metapneumovirus in China, case numbers are now declining. [Associated Press]