At the World Economic Forum in Davos, Switzerland on January 20, 2026, Canadian Prime Minister Mark Carney dispensed with the comforting notion that governance norms and institutions were merely strained in a temporary way. Instead, Carney acknowledged they were breaking.
“We are in the midst of a rupture, not a transition,” Carney told international business and political leaders in a keynote speech.
Few would have guessed that one of the most tangible signs of the rupture would be centered on global health programs.
For decades, the U.S. provided among the largest, most influential sources of health support in the world, delivered largely through the U.S. Agency for International Development (USAID), Centers for Disease Control, and initiatives like the President’s Emergency Plan for AIDS Relief (PEPFAR). A study published in The Lancet estimates that, over the last two decades, USAID-supported global health interventions helped prevent approximately 91 million deaths worldwide by reducing mortality from HIV/AIDS, malaria, and neglected diseases.
Yet in the first days of 2025, the U.S. executive branch dismantled U.S. global health engagement. Relative to 2024 spending levels, Center for Global Development estimates suggest the decline in global health funding could correspond to nearly 1 million additional deaths in a single year. On the ground, stock-outs of antiretrovirals, disruptions in malnutrition treatment, and abruptly suspended services signal real suffering.
At the same time, the Trump administration has leaned into a new form of international engagement: multi-year bilateral agreements with specific countries that replace traditional aid with what are dubbed “America First” health cooperation frameworks.
We need a new vision capable of responding to and advancing justice and health in a transformed geopolitical environment.
The first of these deals, signed with Kenya, reconfigured U.S. support into long-term commitments tied to co-investment by host governments. By December 2025 the U.S. had inked agreements with 14 countries, exclusively in Africa.
Proponents have adopted some of the language of long-standing aid critique to argue that these deals reduce dependency. But what is being sold as autonomy is, in practice, a more transactional and conditional model of engagement that mirrors rather than reduces the colonial relationships critics have long decried. Rather than pools of funding underpinning broad public health capacity, these deals tether resources to geopolitical interests and negotiating leverage.
Moreover, these agreements have not been transparent. Drafts have not been released in full but analysis suggests concerns about restrictive provisions that skew power toward the donor rather than the recipient. This can be seen in data sharing terms, intellectual property constraints, and conditions tied to U.S. foreign policy priorities.
A new vision for global health must move toward mechanisms that treat health as a truly global public good.
And in Kenya, a court order temporarily blocked part of the agreement on constitutional and governance grounds, underscoring the legal and political fragility of these arrangements.
Even without a critique of the old aid model, these shifts reveal something important: The world that produced that model is gone.
We are living in a multipolar age, with rising powers, more middle-income countries asserting their agency, and a decline of the postwar multilateral order. Regionalism and South–South cooperation are on the rise. Institutions like the World Health Organization and the World Trade Organization are being weakened by withdrawal and underfunding, while global crises proliferate.
This is the rupture Carney was talking about: The old norms no longer hold, and nostalgia can’t be the basis for a strategy.
So what should come next instead?
Toward a Vision for a New Foreign Policy
This moment demands a foreign policy that is not about restoring a shattered agency or reviving institutions from a past era. Instead, we need a new vision capable of responding to and advancing justice and health in a transformed geopolitical environment.
A new vision should start with a recognition that the world’s wealthiest countries have an obligation to finance health and wellbeing that does not stop at their borders.
Bilateral U.S. assistance has been critiqued for its heavy strings, political conditionality, failure to support local systems and manufacturers, and decision-making in Washington, DC instead of national capitals and communities. But using that critique of some bilateral programs to justify refusal to support global financing is insincere. Indeed, there are existing mechanisms, especially multilateral ones like the Global Fund to Fight AIDS, TB, and Malaria, that have shown they can achieve remarkable health gains with governance rooted in local decision-making. These should be a starting point for global efforts in a new era.
We can use some of these as a jumping off point to create institutions capable of meeting the moment. They should start with some key priorities: reducing inequality, providing global public goods, supporting civil societies and communities, and shifting U.S. global economic priorities.
Reducing inequality
Inequality is not just a moral failure — it is a driver of pandemics. A recent report from the Global Council on Inequality, AIDS and Pandemics I co-authored shows that inequality within and between countries makes pandemics more likely, more deadly, and harder to control, creating a self-reinforcing cycle that undermines global health security. Inequality is also undermining global cooperation and undermining democracy.
Although reducing poverty and deprivation have been a focus of aid, addressing inequality in itself has not been a goal in a meaningful way. Yet, it could be the focus of how international funding is used into the future.
Providing global public goods
A new vision for global health must move toward mechanisms that treat health as a truly global public good. Global Public Investment (GPI) is one example of a concrete framework for achieving this vision in the real world. GPI involves creating mechanisms for private and public pooled, predictable funding from multiple countries to finance initiatives that benefit everyone — from pandemic preparedness and vaccine research to health system strengthening.
An approach like this could ensure that resources reach communities equitably, support domestic capacity, and provide long-term stability for interventions that protect global well-being.
By investing collectively in shared health infrastructure, the U.S. could help create a system where prevention, treatment, and innovation are global goods. The challenge for this approach is that it has long been rejected by the U.S., who prefers to drive how its funding is applied, thereby historically undermining collective investments. But leaders looking for what might actually work amidst today’s geopolitics could find such an approach would reframe international funding from a series of short-term, conditional interventions to a shared commitment to social resilience, equity, and durable capacity. It could align global health finance with geopolitical realities and in a world where regionalization is growing this could fit.
Supporting civil society and communities
Much of what global health programs have done is not just about money. Instead, it is about building trust, local leadership, and community capacity.
Greater use of national public systems is imperative. But global health investment must also be about strengthening civil society (as bilateral arrangements often have) not just official systems. This is a must for tackling inequality and building truly resilient systems that reach everyone.
The future of global health engagements must be about empowering communities to lead and sustain responses to health threats, systems, and priorities.
Shifting U.S. global economic policies
Finally, the U.S. should not pretend that foreign aid can fix what systemic economic policies break. Policy change needs to tackle the chokepoints of structural inequalities that largely prioritize corporate profits over meeting people’s needs.
The U.S. must confront the bigger structural policies the country has backed over decades that have shaped global inequality and health outcomes. For instance, WTO intellectual property rules often limit access to medicines for countries that cannot afford these high prices. Similarly, IMF and World Bank austerity measures backed by the US have hollowed out health and social services in low-income countries, and unsustainable debt burdens choke public investment that may cultivate independence and prosperity. These are fundamental issues that are central to health security.
Building Toward the Future
One year ago, in January 2025, the collapse of U.S. global health engagement was a shock. Its ongoing, very real impacts challenge any abstract policy defense. Vital programs collapsed before replacements were fully articulated, causing preventable deaths and creating untold unmet medical needs. In the face of such devastation, many backers of global health, human rights, and international solidarity have been instinctively defensive: Preserve what can be preserved, hold tight, and wait until a different administration can reconstitute these programs.
Indeed, the Trump administration’s broad approach to governing is to use executive actions to stop and divert funding without formal rulemaking or legislation. As a result, the administration has left much of the change formally reversible. USAID still exists on paper with a series of acting administrators officially in place — from Secretary of State Marco Rubio to Office of Management and Budget officials.
But simply looking to restore what was is neither sufficient nor likely possible. The rupture in global health is not just a symptom of shifting geopolitics. It is a warning.
In a world where diseases don’t respect borders, where inequalities fuel vulnerabilities, and where cooperation is the only viable defense, retreating into transactional aid or nostalgia for a bygone order is a luxury we cannot afford. The world must build something new, rooted in equity, solidarity, and shared humanity.
