Summary

Global health is fundamentally about shared, universal values—the human rights-based framework. These values underpin the very concept of the ‘global’ of global health, distinguishing it from the technical, disease-control focus of the old “international health.” Technical solutions, while vital, are merely tools to realise the foundational rights that ensure equity and dignity in health. Without this the normative values-based approach of equity and rights, decisions about who receives care risk being driven by wealth, political alignment, or cultural affinity. It will destroy global health.

The AIDS crisis marked a pivotal shift, marking the beginning of global health. Through advocacy and international cooperation it reframed health as a universal right. Yet this hard-won progress has been in decline for the past 20 years and faces existential threats. A second Trump administration promises deeper erosion of multilateralism, international aid, and rights-based approaches. Health will become a geopolitical bargaining chip in a transactional world of nationalist posturing—its moral foundation stripped away. As authoritarianism rises and equity erodes, global health is on life support: reaffirm universal rights or surrender to a transactional, fragmented future.

Introduction

About a year ago, I started writing an article on the decline of global health. We could all see the trend of nation-states withdrawing into more populist, authoritarian, and revanchist postures. Divided nations are ill-suited to a global agenda of working together for a common good. A flock of authoritarian governments congratulating each other today is no basis for future global cooperation. Nonetheless, if I wanted to make the case, I needed to be more explicit about the link between a fracturing the global order and global health.

As the 2024 U.S. election approached, this article—a dozen drafts in—became increasingly difficult to write. It was missing a pivotal data point. Now that data point has been colored-in and the post-inflection trajectory is clear.

We should be worried about the future of global health.

On 20 January 2025, Donald Trump will succeed Joe Biden as the President of the United States (U.S.). He will become the 47^th President. Trump Republicans (not the old-school Reagan Republicans) won back the U.S. Senate and will retain the House. The election wasn’t close. Every single state swung Republican, even the ones that the Democrats held. Trump won comfortably—316 Electoral College votes, all the “battleground” states and the popular vote. He will control the Executive, the Senate, and the House.

Six of 9 Justices on the Supreme Court are conservative. He appointed three of them, and as a block, the conservative justices no longer pay even nodding respect to judicial restraint.

Trump campaigned on a racist, populist platform of “America First”. He has won that mandate.

The premise of Trump’s first term in office (2017-2020) was unfettered executive authority. He signed more Executive Orders in his first term than any other 21^st Century president signed in any single term. It annoyed him that he did not always get his way. He would name some outrageous or illegal thing and wait for it to happen. Minders would walk it back. They learned not to contradict him but to “delay, procrastinate, cite legal restrictions”. They hoped he would forget or turn to a new target of vengeance. Congress retained some norms of the democratic process, which moderated his Executive authority. The Supreme Court had not yet been unleashed.

Restraint will not happen in Trump’s second term. He has learned. The next administration will be more disciplined and more driven. They now understand that democratic norms are unenforceable soft guardrails of expected behaviour. They hold no force for Donald Trump. The new administration will not hold back, and neither Congress nor the courts will be effective accountability mechanisms.

I will outline what this shift means for global health, starting with a clear definition of what “global health” entails. From there, I will chart the ongoing decline in global health and the reasons behind it. Finally, I will turn to the implications of Trump’s second term, explaining why it represents not just a continuation of decline but a death knell for global health as we have known it.

Global health

Ask most experts about global health, and you’ll hear about technical fixes. They’ll discuss effectiveness, cost-effectiveness, health systems, health financing and evidence-based policy. Embedded within these ideas, you may also hear about normative values ideas like ‘equity’ and ‘rights’. Some people may also mention transnational health issues like pandemics, global governance, and treaties.

Most global health experts will focus on countries in Africa, Asia, and Latin America—countries with a GDP per capita below (something like) USD$15,000. They will probably use shorthand phrases to describe their geographies of interest, like “Global South”, “LMIC” (low- and middle-income country), “Developing Countries”, or for the hip, “Majority Countries”. They will talk as if wealthier countries are not a part of global health’s world.

I have a different take (and a few others have expressed related ideas). Global health is entirely a proposition about our shared, universal values. When we lose sight of those universal values, we lose the ‘global’ of global health. The technical work is the icing on a values cake; it is the stuff that made up the old “international health”.

This idea may seem counterintuitive. Surely the technical work that saves lives is the cake? No! Without its foundation in universal values, decisions about who, how, when, and why we help people rely on personal or political whims. We might neglect certain groups, impose ineffective interventions, or prioritise other groups for help based on their superior wealth, political allegiance, or cultural affinity.

The preamble to the Constitution of the World Health Organization, written in 1946, establishes that people have a right to the highest attainable standard of physical, mental and social well-being. Health is a fundamental right, but it is not just an end in itself. It is also a means to other ends. This means-end distinction is evident across the different human rights instruments, which apply “without distinction of any kind, such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status”.

We have a universally recognised right to life, liberty and security of person free from slavery or servitude, a right to privacy, a right to freedom of thought, conscience and religion, and a right to freedom of opinion and expression…. We have a right to dignity, equality and self-determination. And we each have these rights in virtue of no more remarkable quality other than being human. All these rights are rendered hollow, however, without the health necessary to exercise them. To save a life that is then diminished by preventable suffering, betrays the fundamental human dignity these rights are meant to protect.

Global health is anchored in these rights because health is both an end in itself and a means to other ends. Simply put, without health, the pursuit of everything else becomes unattainable. While technical approaches to global health, like Sullivan’s recent piece in The Conversation, focus on effective health systems, they lack force without the foundation of universal human rights. Normative values and technical solutions are not oppositional; technical solutions are tools to realise fundamental rights, and they cannot achieve ‘health for all’ without this underlying rights framework.

This straightforward enunciation of universal human rights carries profound implications. States aim to improve their population’s well-being while, where possible, assisting other states in doing the same. As states pursue the interests of their own population, they must also avoid harm to others. On a global scale, we must balance our benefits and losses against those of others. One country cannot pursue its population’s well-being at the complete expense of another.

Global health demands we acknowledge and address this interconnectedness. The pursuit of well-being in one nation often has significant repercussions for others. The industrial progress that drives prosperity in one country cannot justify the harm inflicted on populations in another through choking air pollution carried by prevailing winds. Nor can a country justify genocide—whether within its borders or abroad—under the guise of national security. In every case, we must carefully weigh individual or national benefits against potential harms. Sometimes, this means accepting that everyone becomes somewhat worse off to avoid sacrificing one group’s well-being for minimal gains elsewhere.

This shift from the technical approaches of international health toward a framework grounded in universal rights compels a far more profound question to be asked. How do we improve health everywhere and deliver it to everyone—because it is their right?

Global health’s decline

The AIDS crisis catalysed the paradigm shift from the technical focus of international health on disease control to a normative approach grounded in equity and rights. Initial responses to HIV/AIDS had often moralised transmission routes—sex and injecting drug use. Stigma and discrimination were the consequence. As the epidemic grew—particularly as it generalised into the wider population in sub-Saharan Africa—vast inequities in health access and outcomes were exposed. A global response emerged, drawing on pre-existing rights-based instruments to reframe health as a universal human right. Although the right had long existed, the call on that right was novel. Advocacy networks and transnational institutions mobilised to address health as a shared global responsibility. They demanded international cooperation, political commitment, and sustained funding. UNAIDS was created in 1994.

In challenging the notion that individuals could forfeit their right to health through “bad behaviour”, this movement affirmed that local laws or cultural norms could not justify violations of universal human rights. In bridging international health’s technical focus with human rights principles, the crisis shaped global health as a distinct field.

Today, the term “global health” is ubiquitous. In the academic literature, its use accelerated from the mid-1990s, and by the early 2000s, it began to appear frequently in the popular press. Even with the success of this new health movement grounded in a rights-based approach, within 15 years of global health’s arrival on the world stage, the seed of its decline was planted. The decline arose from an interplay between geopolitical forces that were callously disinterested in the lives of millions of people and cultural, doctrinal, and political forces that regarded ideas of universal normative principles anathema. The history of global health’s decline is characterised by three intersecting waves. The first wave was U.S. exceptionalism.

Geopolitically, President George W. Bush declared a “global war on terror” in 2001. The U.S., the champion of universal rights and a multilateral system, now argued for its own exceptionalism. It claimed a special privilege to ignore those very rights it championed (justifying extrajudicial killings, torture, and detention without charge) [see here and here]. It destroyed national infrastructure in foreign countries and inflicted massive civilian casualties. It dragged countries into conflict on flimsy evidence and a thirst for vengeance over the 9/11 attacks. The U.S. postured the victim while acting as the aggressor.

The U.S. shift away from universal rights in favour of exceptionalism signalled a turning point. Other countries followed suit. The U.S. arguments were embraced and refined. Identify a group as terrorists or a country as a safe harbour for terrorists, and that was all the justification needed to crack down on civil and political rights, intern minorities, or seize territory. Following the U.S. playbook, evidence was irrelevant. Any international objections smacked of hypocrisy and were swatted away.

The second wave was based on cultural counter-narratives. While the U.S. government had claimed to be exceptional, it did not renounce the rights-based framework or the multilateral order. Rather, the U.S. continued to champion it. Do what I say, not what I do.

Other nations seized on the U.S. precedent of exceptionalism and took it further. Rather than merely claiming exceptional circumstances, they developed arguments against the universality of human rights itself. These counter-narratives drew on claims of traditional values, unique cultural heritage, threatened identity, or religious doctrine to argue that universal rights were a Western ideological fiction and not truly universal. Such claims were not new, but they were given oxygen by Western action. The narrative transformed the U.S.’s circumstantial exceptionalism into a fundamental challenge to the legal underpinnings of global health.

China evolved the counter narrative to universal rights using the idea of the “universally exceptional”. Every nation, it argued, has a unique identity and heritage that makes its values distinct and non-comparable to others. At first glance, this might appear pluralistic—an embrace of diversity. In practice, it serves as a carte blanche to dismiss universal rights altogether. Under this framework, the state becomes the sole arbiter of what is good and right, sweeping aside the claims of minorities, dissidents, or those who deviate from the state’s preferred narrative. This relativist shift doesn’t just weaken global health—it dismantles its core, giving space to the third wave of its decline.

The third wave aimed at dismantling multilateral institutions and treaties. The first Trump presidency saw the U.S. withdrawing from the multilateral system. It either withdrew from agencies and treaties completely, withdrew funding, or publicly abused and denigrated the agencies and treaties.

The agencies the U.S. attacked included UNESCO (withdrew 2017), the United Nations Human Rights Council (withdrew 2018), WTO (threatened to withdraw 2018), WHO (threatened to withdraw 2020). It withdrew funding from UNFPA (2017) and UNRWA (2018).

In addition to attacks on multilateral organisations, the Trump administration also threatened, suspended or withdrew from treaty arrangements, including the North Atlantic Treaty Organisation (NATO) (threatened to withdraw in 2017), the Paris Climate Agreement (withdrew in 2017), and the Intermediate-Range Nuclear Forces Treaty (INF) (suspended in 2019).

The Trump administration reimposed a more brutal version of the “global gag rule”. Republican administrations since Ronald Reagan had restricted global family planning organisations from receiving U.S. government funding if they used any funding (including their own funds) to make reference to abortion or to provide abortion services. The Trump Administration expanded the global gag rule to all international non-government organisations (INGOs), affecting hundreds of millions in funding. It forced INGOs to choose between receiving U.S. funding or abandoning critical health rights. UN Agencies also modified their behaviour to conform to the wishes of the U.S.. The administration’s policy aligned with extreme, conservative Christian ideas that undermined universal rights including the right to life, liberty, security of person, and privacy—and it particularly affected the rights of women in the poorest of countries.

Abortion is a divisive issue, and passions run hot. It, thus, functions as a canary in the coal mine for global health.

No rational person wants women to have an abortion. They want women never to have to have abortions, and this works best when women have choice and control over their own sexual and reproductive lives. When other options fail, women should be able to choose an abortion—as is their right.

In the U.S., religious extremists believe that people—particularly women—are either so mentally incompetent or morally bankrupt that they cannot be trusted to make choices about abortion or contraception. By removing choice choice about when (or if) women have children and how they space those children, extremists implicitly advocate for the idea that some lives (women’s) exist as the means to others’ ends. They essentialise the sexual and reproductive life as an inflexible, pre-determined role where the desires, hopes, and health of the mother do not merit consideration because the ultimate purpose of a woman is as a vessel for another life.

In the last days of the his presidency, the U.S. Ambassador to the UN presented a letter to the UN General Assembly, the so-called “Geneva Consensus Declaration” (GCD). The letter claimed to “support women’s rights and optimal health” while speciously attacking the idea of a right to abortion. One of the most telling claims in the declaration is about “… the sovereign right of every nation to make its own laws protecting life, absent external pressure”. “Absent external pressure” means that governments are not beholden to the human rights frameworks they signed on to.

The last couple of years have given rise to a contemporary crisis, accelerating the decline in global health. Russia’s invasion of Ukraine in 2022 and Israel’s response to the Hamas attack in 2023 have exposed the highly selective nature of Western commitments to human rights and humanitarian protection. While Western powers condemned Russian aggression and invoked international law, their support for Israel’s military response in Gaza has led many countries in the Global South to view the rules-based order as fundamentally hypocritical.

The U.S. position on Gaza, prioritising Israel’s right to self-defence over mounting evidence of Israeli war crimes and massive civilian casualties, has undermined its moral authority as a defender of universal human rights. On 21 November 2024, the International Criminal Court (ICC) issued arrest warrants for “Benjamin Netanyahu [Prime Minister of Israel] and Mr Yoav Gallant [Defense Minister], for crimes against humanity and war crimes committed from at least 8 October 2023 until at least 20 May 2024”. In response, Joe Biden described the warrants as ‘outrageous’, and through false equivalence, suggested that Netanyahu and Gallant could not have committed crimes unless their behaviour was as bad or worse than that of Hamas’s leadership. Hungary declared it would ignore the ICC warrant and France falsely claimed the warrant had no legal basis because Israel was not a party to the ICC.

The cumulative effect of the three waves of decline and current events have left global health battered.

Trump’s second term

The second term is viewed by some as something uniquely catastrophic. Don’t get me wrong—it is terrible. However, Trump 2.0 is not a sudden or novel threat to global health. It marks the continuation of the same decline, with a steeper gradient.

The foundations of global health were already weakening. The Biden administration temporarily slowed the decline of global health by re-engaging with the multilateral system and reversing the gag rule on reproductive rights. However, it was also under Biden’s presidency that Israel launched its devastating assault on Gaza, killing tens of thousands of Palestinians—most of them women and children. The assault was enabled physically by U.S. weapons and politically by vetoes in the Security Council against resolutions aimed at condemning or constraining Israel’s actions (AP News, UN News). These contradictions underscore the fragility of the global rights framework.

Under Trump’s second term, the erosion of these frameworks will likely accelerate, with far-reaching consequences. Domestically, Trump’s presidency is expected to dismantle a wide range of human rights protections while preserving a democratic veneer. The calculated erosion of rights will serve as a dangerous signal to other nations, demonstrating that authoritarianism can thrive within the hollowed out structures of democracy, as seen in Hungary and India (Lowy Institute, HRW, The Conversation). Early indications of Trump’s intent to consolidate power are evident in his floated proposal to bypass Senate oversight for Cabinet appointments, his post-election embracing of the Project 2025 team, and his nomination of billionaires—such as Elon Musk and Vivek Ramaswamy—to lead a newly created “department” of government efficiency (DOGE). This department, ostensibly aimed at reforming government will dismantle the administrative state, undermining the rule of law and centralising power (Vox, USA Today, WSJ, Independent).

Internationally, Trump’s administration will likely mount a more determined assault on the multilateral system than in his first term. Institutions will face delegitimisation, defunding, and the insertion of politically aligned officials into senior roles. Parallel structures, of like minded authoritarian governments may emerge to further undermine the credibility of global governance frameworks. Under such conditions, the independence of international officials and the foundational values of multilateralism will be compromised, leaving defenders of the system isolated and underfunded (UN Ethics Guide).

The most dangerous consequence of Trump’s presidency, however, will be its emboldening effect on nations that have already abandoned the principle of universal rights. China’s state-centered governance model, Russia’s aggressive nationalism, Israel’s ethno-religious exceptionalism, and India’s Hindu nationalism all offer alternatives to universal human rights, presenting them as Western fictions now abandoned by the West itself. The shift will be fundamental: from a world where universal rights are acknowledged, even when violated, to one where they are openly rejected. In this new reality, global health—built on the foundation of universal human rights—becomes impossible to sustain. (Arizona Law Review, Lowy Institute, Ian Bremmer).

Impact

In a fragmented, transactional world, coordinated action will become challenging. The pandemic treaty is already stuttering, and it is increasingly unlikely that it will be signed. Funding for multilateral agencies and international health initiatives is likely to be disrupted. Countries will act alone or in cliques to support their own strategic priorities, leaving the multilateral agencies struggling for core administrative funding.

HIV/AIDS, which once served as the launchpad for global health, now faces an existential threat. The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) is the largest commitment to LMICS by any country to manage a single disease—about $6 Billion a year. In a transactional world, African nations from Angola to Zimbabwe may be forced to offer significant concessions to maintain U.S. support. Without it, decades of progress against HIV could unravel rapidly.

The future of other global health initiatives, such as efforts to combat malaria, tuberculosis, maternal and child mortality, and neglected tropical diseases, is equally bleak. The U.S. could save $12 Billion a year by withdrawing from the global health space and putting “America First”. Robert F. Kennedy Jr, a well-known vaccine denier, is the Trump pick for Health Secretary. He has already declared a desire to move the focus away from infectious diseases and reduce the global reach of the NIH and CDC. The shift in focus will have the additional effect of weakening already weak health systems in LMICs.

Sexual and reproductive health and rights will face renewed assault. A more muscular version of the global gag rule will be reinstated, cutting critical funding for family planning services. Increased maternal and infant mortality will follow, compounded by the rise of pro-natalist policies globally. U.S.-based global health philanthropies may face regulatory restrictions on funding international family planning efforts. While “money as free speech” has historically protected these efforts (per theU.S. Supreme Court’s Citizens United ruling), a determined administration has numerous levers to curtail such funding flows to foreign states.

If other wealthy nations attempt to fill the gap left by U.S. retrenchment, they are unlikely to compensate fully for the shortfall. International NGOs (INGOs) will see their capacity and reach diminish. Coordination, already a perennial challenge in global health, will become nearly impossible without strong mechanisms to prioritise and harmonise action.

Health will cease to be a universal right. Instead, it will become a tool of political leverage. Aid and support for health will be increasingly tied to political compliance, transforming medical infrastructure into a geopolitical bargaining chip.

In this new order, health will be subordinated to state interests, valued not as a right but only as a means to serve political or economic ends. Social stratification in health outcomes will deepen, as the intrinsic value of individuals erodes in the absence of universal rights or personal agency. People will no longer be regarded as “born free and equal in dignity and rights.” They will become transactional commodities, valued only by their utility to the state. A woman’s worth will be reduced to her reproductive capacity. An indigenous person’s worth will depend on their conformity to dominant cultural norms. A disabled person may be deemed valueless. A Christian, Muslim, or Jew may be labeled a threat.

Conclusion

Global health, as an embodiment of universal rights and shared responsibility, will probably end. The underpinning, normative values of equity and rights are eroding under the weight of authoritarianism, cultural relativism, and geopolitical fragmentation. The second Trump administration will exacerbate these trends, accelerating the decline of multilateralism and legitimising the open rejection of human rights. In this new reality, global health risks becoming unrecognisable—a domain stripped of its moral foundation. Health will return to its pedestal of a privilege reserved for the politically compliant or economically strategic.

The challenge ahead is monumental. Defenders of global health must rally around its core principle: universal human rights support wellbeing. They support the reality that health is an end in itself and a means to other ends. This will require a reinvigorated commitment to multilateralism, a rejection of transactionalism, a refusal to compromise on normative values, and a recognition that technical solutions are meaningless without a rights-based framework. The stakes could not be higher. If we lose the global in global health, we lose not just a field of practice, but the very idea that health is a shared human endeavour. And when that idea dies, what follows will be very dark.