Critics of the Trump administration’s early actions on global health—withdrawing from the World Health Organization (WHO) and paralyzing U.S.-funded international health programs—fear that those moves will cede Washington’s longstanding leadership role to Beijing. American power and prestige, they charge, will wane, and China’s will grow.
The reality is worse. A U.S. retreat on global health, if sustained, will indeed open the door for China to exploit the abrupt, chaotic withdrawal of U.S. programs in some strategic regions. China is already providing replacement funding in Southeast Asia, and it may do the same in Latin America. But in most of the places that U.S. aid targets, including those at the greatest risk from disease, China will not step in. China’s leaders are focused on using aid to build influence with strategic partners; they have no desire to take up the U.S. role in preventing, detecting, and responding to the world’s most dangerous diseases.
Without sustained support for either international institutions or health programs in the world’s poorest countries, the result will be a vacuum in global health that will make everyone less safe. The greatest risk to Americans is not that China will supplant the United States as the world’s leader in global health. It is that no one will.
THE HOUSE AMERICA BUILT
For 25 years, U.S. funding, diplomatic heft, and technical expertise have enabled remarkable progress in global health. A slew of international institutions and programs, primarily created and funded by the United States, targets diseases that poor countries cannot fight alone with medical solutions that need scale and infrastructure only an international coalition can provide.
U.S. support for global health is a small part of the country’s domestic budget but a huge part of international health funding. In 2023, U.S. global health spending represented about 0.3 percent of federal spending ($20.6 billion out of the $6.1 trillion U.S. budget). Yet that same year, the United States was responsible for nearly three-quarters of international development assistance for HIV/AIDS, 40 percent of malaria aid, and more than a third of funding to combat tuberculosis. Until this year, the United States was also the single largest funder of the WHO; the biggest provider of vaccines to the multilateral COVID-19 vaccine initiative; and the driving force behind the Pandemic Fund, a World Bank vehicle that invests in low-income nations to prevent infectious disease outbreaks.
Millions of people in the world’s poorest countries benefit from U.S. aid. Organizations and programs funded by the United States, including the WHO, the vaccination alliance known as Gavi, and the Global Fund to Fight AIDS, Tuberculosis, and Malaria, provide vaccines, care and treatment, and other lifesaving interventions across the globe. Nearly 21 million people with HIV depend on the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) for lifesaving antiretroviral therapy. Gavi helps immunize nearly 70 million children each year against deadly pediatric illnesses. Nearly three-quarters of bilateral U.S. health aid went to countries in a single region: sub-Saharan Africa.
The returns on these investments have been spectacular. Since PEPFAR began in 2003, global deaths from HIV/AIDS have fallen by more than 50 percent. The number of people dying from tuberculosis and malaria has declined by a third over the same period. In 2000, there were 42 countries, including most of sub-Saharan Africa, where at least one out of ten children died before his or her fifth birthday. Today, there are four such countries.
The benefits from U.S. aid go beyond fewer deaths from specific diseases targeted by individual programs. American aid workers also help the world better prepare for all manner of future health threats. USAID and the Centers for Disease Control and Prevention have worked with health ministries in 90 countries on developing systems to track outbreaks, from HIV to the H5N1 avian flu. U.S. dollars funded the laboratories, training, and research that enabled scientists to sound the alarm when the first COVID-19 case was identified outside China. An emergency operations center funded by American aid to fight polio helped avert disaster in 2014, when the Ebola virus nearly spread to the densely populated streets of Lagos, Nigeria. And U.S.-funded research developed the vaccine the world currently depends on to stop the spread of mpox.
Each of these experiences comes with a lesson: if outbreaks of deadly diseases are not stopped at the source, they risk spreading across the globe, with devastating results for everyone. Better health in the world’s poorest places means better health for other countries, too, including the United States.
UNHEALTHY RELATIONSHIP
As the United States has abandoned the field of global health, China has started to exploit the ensuing chaos. In Nepal, Chinese officials have reportedly reassured local politicians that Beijing is “willing to assist if Nepal faces challenges in humanitarian aid, health, and education.” In Cambodia, China has announced new funding programs for child health, nutrition, and sanitation and stepped in with a $4.4 million grant to fund the removal of land mines, all in the first six weeks after U.S. President Donald Trump ordered a freeze on USAID funding. In Bangladesh, the director of a local association of development agencies told reporters: “We need to diversify our funding. China is also a good friend of Bangladesh.” And Hu Zhangliang, a vice chairman of the China International Development Cooperation Agency, has promised: “We will not behave like some countries that leave aid recipients feeling helpless, caught off guard, or unprepared.”
Yet China’s recent track record in development assistance does not match its rhetoric. The country has not prioritized multilateral programs, cross-border disease threats, or aid to the poorest countries. It is also skeptical of international global health bodies and has a complex, sometimes strained relationship with the WHO. Those looking for salvation from Beijing are likely to be disappointed.
Take the WHO. Although China was a founding member, it was not until the aftermath of the 2002-3 SARS epidemic that the country began to take its relationship with the organization seriously. China’s Ministry of Health had known of a dangerous new strain of pneumonia in Guangdong Province for months before it shared that information with the Chinese people or other governments. As the SARS epidemic expanded, ultimately spreading to 29 countries and killing nearly 800 people, Gro Brundtland, then the WHO’s director general, publicly rebuked China for its lack of transparency and issued the organization’s first-ever travel advisory, warning against visiting Guangdong and Hong Kong.
Hoping to repair the reputational damage, China stepped up its engagement with the WHO. China joined the WHO’s virtual laboratory network, helped rewrite the organization’s international health regulations, and invested in disease surveillance. In 2006, the former Hong Kong health director Dr. Margaret Chan was elected WHO’s director general—the first Chinese national to lead a major UN organization.
Closer ties paid dividends for China. Since 2017, acting under Chinese pressure, the WHO has shunned Taiwan, abandoning its practice of inviting the country to participate as an observer at the World Health Assembly. In 2017, the WHO signed an agreement with China to jointly implement the country’s development agenda, the Belt and Road Initiative, and, in 2019, the WHO added traditional Chinese medicines to its International Classification of Diseases.
The returns on U.S. investments in global health have been spectacular.
When news emerged of a new coronavirus outbreak in Wuhan in January 2020, the WHO refrained from criticizing Beijing’s response. Caution was hardly surprising: the organization relies on cooperation from member states and prizes solidarity in a crisis. But the deference to China went further than normal. Allegedly under Chinese pressure, the WHO delayed declaring the outbreak a public health emergency of international concern for a week, until late January. China had been slow to share the extent of human-to-human transmission in the crucial early phase of the outbreak and reluctant to provide biological samples to the WHO, but a WHO official praised Beijing for its “openness to sharing information.”
Although this support earned the WHO goodwill in China—WeChat and Weibo users affectionately dubbed the WHO’s Ethiopian director general, Tedros Adhanom Ghebreyesus, “Secretary Tan,” a term typically used for Chinese Communist Party officials—it attracted the ire of the United States. Eager to shift the blame for his administration’s flailing response to COVID-19, Trump suspended U.S. funding to the WHO in April 2020 and later announced that the United States would withdraw from the organization. It was too “China-centric,” he declared. Beijing swiftly capitalized on the diplomatic opportunity, pledging an additional $30 million to help make up the shortfall in U.S. funding.
Despite the boost in Chinese funding, the WHO responded to U.S. anger by distancing itself from Beijing. When scientists criticized the preliminary findings of a joint study by the WHO and China on the origins of COVID-19, Tedros departed from the WHO’s typical deference to China. He argued that the study had not ruled out the possibility that the virus had leaked from a Chinese lab, and he encouraged China’s cooperation with a second phase of the investigation. China rejected the request, and the Chinese media accused Tedros of having become “America’s mouthpiece.”
Tensions continued after the pandemic. In 2023, China reportedly balked at a 20 percent increase in its WHO contributions. The same year, Tedros allegedly rejected China’s preferred candidate for the post of assistant director general and instead promoted a senior WHO staff member. China has been lukewarm toward a proposed new pandemic treaty, a WHO priority, sending low-ranking officials to the negotiations and adopting what one Chinese observer characterized to us as a “not opposing but not hoping to happen” stance.
Since Trump once again promised to withdraw the United States from the WHO in January, China has seemed reluctant to fully replace the U.S. role. In February, it signaled that it planned to oppose a scheduled increase in member dues that would bring contributions more in line with each country’s GDP. Although China will become the WHO’s largest contributor of assessed funding after the United States withdraws, member state dues accounted for just 12 percent of the organization’s budget in 2023. Beijing is unlikely to make up most of the U.S. contribution, the majority of which consists of voluntary funding.
China’s reluctance to fill the financial hole left by the United States will likely extend to other multilateral institutions, too. So far, Beijing has contributed relatively little to most global health organizations, preferring bilateral approaches over multilateral ones. Before the COVID-19 pandemic, Beijing spent an estimated $600 to $800 million annually on health-related foreign aid, with only 10 percent of that total flowing through multilateral channels. China began donating to Gavi in 2016, but its non-COVID funding has amounted to just $25 million over ten years, compared with a U.S. contribution of more than $2 billion in the past five years alone. China’s contributions to the Global Fund are likewise modest: whereas the United States, the fund’s largest donor, has contributed more than $26 billion, China has pitched in just $90 million, behind 21 other governments. Of the $3.6 billion the world contributed to the UN’s Ebola Response Fund, China provided $47 million (just over one percent of the total) while the United States donated $1.8 billion (49 percent).
CHINA FIRST
Many individual countries, like international organizations, will seek China’s help to replace U.S. funding, but recent trends in Beijing’s bilateral aid suggest that most are unlikely to get it. In 2023, China’s bilateral health development assistance—funds that flow directly to recipients rather than through international organizations—declined to its lowest level since 2010. And as its overall spending has fallen, China has concentrated its dollars less on the greatest threats to global health and more on advancing its national interests.
To that end, much of China’s recent health assistance has targeted countries participating in its Belt and Road Initiative. This has meant shifting its earlier support from malaria control aid projects in Africa to infrastructure-driven investments in Southeast Asia and Latin America. China’s aid in Africa has not vanished entirely: it continues to contribute to some high-visibility health projects, such as the newly completed headquarters and a high-security laboratory for the Africa Centers for Disease Control and Prevention in Addis Ababa. Beijing Genomics Institute, the Chinese genomics research giant, has provided low-cost gene sequencing technology to some African countries for infectious disease surveillance, as part of its efforts to, in its own words, “seize the commanding heights of international biotechnology competition.” But the trend is unmistakable. Fifteen years ago, four of the top five recipients of Chinese health aid were African countries; today only one is.
China’s COVID-19 aid adhered even more closely to the country’s geopolitical interests. Starting in April 2020, China launched a campaign to brand itself a leader of the global pandemic response, sending masks, test kits, medical teams, and, ultimately, vaccines overseas before the United States and most other donors of essential medical supplies did so. But China’s donations went overwhelmingly to countries in its backyard, not to those that needed them most. In the first year after the vaccines became available, China directed nearly three-quarters of its donated doses to Southeast Asia, South Asia, and the Pacific. Cambodia received so many Chinese doses that it began re-donating them elsewhere in Asia. Guyana and Nicaragua received Chinese vaccines shortly after reaffirming the “one-China” principle or switching their diplomatic recognition to China over Taiwan during the pandemic. While the Biden administration also earmarked some of the earliest U.S. vaccine doses for the strategic Indo-Pacific region, more donated U.S. vaccines in the first year went to the regions where death rates were highest (Latin America) or supplies were lowest (sub-Saharan Africa).
THE SOUND OF SILENCE
When the Trump administration’s 90-day review of U.S. foreign assistance ends on April 19, it is unclear what will remain of the global health ecosystem that U.S. leadership painstakingly built over the past 25 years. For one thing, whatever the United States does next, the disruption it began will continue to spread. Argentina, echoing Trump, withdrew from the WHO earlier this month, and Hungary and Russia have reportedly explored doing the same. The United Kingdom, the largest donor to Gavi, recently announced that it would slash development assistance from 0.5 percent of GDP to 0.3 percent by 2027 in order to increase defense spending in response to the wavering U.S. commitment to Ukraine. France’s cash-strapped minority government has proposed cutting its aid budget by up to 40 percent. The recently elected German government may find it hard to sustain Germany’s commitment to the WHO amid growing economic pressure and higher defense spending. Facing low consumer confidence, a long-running real estate crisis, and an escalating trade war with the United States, China has signaled it will concentrate its dollars less on foreign aid and more on advancing “high-quality development and high-level security” at home. The Gates Foundation, though a possible source of additional funding, traditionally favors earmarked contributions (such as for polio eradication) rather than general support for WHO operations. Local governments are exploring how to shoulder more of the burden, but this may not be possible everywhere, especially in sub-Saharan Africa, where countries spend, on average, just $92 per person on health each year.
In this environment, there is a real risk that China will seek to exploit the disruption in U.S. foreign assistance to strengthen relations with key Southeast Asian and Latin American nations. But the greater risk to Americans and people around the world is that for most diseases in most places, U.S. support for global health will be replaced by nothing at all.
Some specific U.S. disease programs may survive, such as the distribution of anti-malarial bed nets, and antiviral therapy and drugs to prevent the transmission of HIV from mother to child. But as U.S. health security programs dissolve and multilateral health institutions struggle to pay their bills, the intricate network of disease prevention, detection, and response that protects everyone—Americans included—risks unraveling. By dismantling this architecture of vigilance, the United States will create blind spots where emerging diseases can incubate before they arrive fully fledged on the country’s doorstep. That will create an illusion of safety—until it is too late.
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