After his inauguration on January 20, President Donald Trump signed an initial tranche of executive orders to implement his domestic and foreign policy priorities that send U.S. foreign policy on global health in new directions and that portend more changes as his second term proceeds. Trump's return to the presidency came with promises and expectations that his foreign policies would differ from those of former President Joe Biden. Based on the initial executive orders, those differences concerning global health are profound.
America First 1.0 and Global Health
Global health falls within overarching foreign policy frameworks. As during his first term, President Trump's America First strategy defines his foreign policy. In one executive order issued last week, he proclaimed that U.S. foreign policy "shall champion core American interests and always out America and American citizens first." He directed the secretary of state to bring the Department of State's "policies, programs personnel, and operations in line with an America First foreign policy, which puts America and its interests first."
During Trump's first term, his America First foreign policy did not embrace the U.S. global health leadership that had developed with bipartisan support since the early 2000s. Tensions arose when, for example, Congress rejected the Trump administration's proposed cuts to global health spending. However, long-standing U.S. initiatives, including the President's Emergency Plan for AIDS Relief (PEPFAR), largely continued without major disruption.
U.S. global health leadership did not include sustained U.S. commitment to climate diplomacy
Trump's withdrawal from the Paris Agreement on Climate Change (Paris Agreement) ended President Barack Obama's efforts to make mitigation and adaptation central to U.S. foreign policy. Trump's rejection of climate policies, however, replayed the decades-long political dissonance in the United States about climate change. That dissonance meant that U.S. global health leadership did not include sustained U.S. commitment to climate diplomacy.
The rupture between Trump's America First foreign policy and U.S. global health leadership happened in 2020 during the COVID-19 pandemic. Trump did not demonstrate global leadership against a killer pandemic, started to withdraw the United States from the World Health Organization (WHO) amid that crisis, and took an America First approach to vaccines produced by Operation Warp Speed.
Against that track record, Trump's return to office has raised questions about how America First 2.0 handles global health. Several executive orders in his first week back in the White House began to flesh out what U.S. global health involvement will look like. Some send the U.S. government in definitive directions concerning global health. Others, including the America First directive to the secretary of state, established processes that will shape how the United States engages on global health issues for the next four years.
Withdrawal from the World Health Organization
Trump's loss to Biden in 2020 meant that his first attempt to withdraw the United States from the WHO failed. His second attempt, contained in an executive order, will succeed. When the withdrawal is complete, the United States will not, for the first time in 80 years, be a member of the primary international health organization.
In the order, Trump asserts that the WHO mishandled the COVID-19 pandemic, has failed to enact needed reforms, has not remained independent from the political influence of WHO members, and requires the United States to bear a disproportionate share of the organization's assessed contributions, especially relative to what China pays.
The withdrawal order also pauses transfers of U.S. funds to the WHO, recalls all U.S. personnel or contractors working with the WHO, rescinds the U.S. global health security strategy that the Biden administration issued, ceases U.S. participation in the negotiations on the WHO Pandemic Agreement and amendments to the International Health Regulations (IHR), and directs that neither the agreement nor the IHR amendments are binding on the United States.
The executive order recognizes that withdrawing from the WHO requires policy adjustments. It instructs the national security advisor to "establish directorates and coordinating mechanisms within the National Security Council" to "safeguard public health and fortify biosecurity." The order directs the secretary of state and the director of the Office of Management and Budget to "identify credible and transparent U.S. and international partners to assume necessary activities previously undertaken by the WHO."
Withdrawal from Climate Change Diplomacy
Since the Paris Agreement was adopted in 2015, the health threats posed by climate change have become prominent in climate diplomacy. Biden addressed such adaptation challenges in trying to provide U.S. leadership. Several executive orders that Trump signed on January 20 dismantle Biden's related domestic and foreign policies.
Trump ordered that the U.S. government begin the formal UN process to withdraw the United States from the Paris Agreement, with all U.S. obligations under the agreement ended immediately on the filing of the withdrawal notice. The order also ended, with immediate effect, any U.S. financial commitment made under the UN Framework Convention on Climate Change and terminated the U.S. International Climate Finance Plan. Finally, the order instructed the secretary of state and all other department and agency heads to "prioritize economic efficiency, the promotion of American prosperity, consumer choice, and fiscal restraint in all foreign engagements that concern energy policy."
Trump also issued executive orders that declared a national energy emergency and that seek to unleash American energy to boost U.S. fossil-fuel production, including the revocation of domestic and international climate policies that the Biden administration enacted. Trump also withdrew offshore areas from wind energy leasing and ordered a review of federal wind project leasing and permitting practices—a measure intended to stifle the growth of renewable energy.
Reform of U.S. Development Assistance
For decades, improving global health has been important in U.S. foreign aid. In an executive order, Trump asserted that past U.S. foreign assistance is "not aligned with American interests and in many antithetical to American values." He instructed department and agency heads overseeing development assistance to immediately pause disbursement of funds to permit a 90-day review of U.S. aid programs. The secretary of state can waive the pause requirement for specific programs. The review is to make recommendations on continuing, revising, or ending programs based on whether they are fully aligned with Trump's foreign policy.
How U.S. global health assistance fares in the review process depends on whether those assistance programs fully align with the America First foreign policy. The controversy over PEPFAR and abortion before the 2024 election indicates that even effective programs face scrutiny under the Trump administration's formulation of American interests and values. Trump wants U.S. development assistance transformed, so the process is likely to produce significant policy reforms and budget cuts for programs that continue as well as new initiatives perceived important for America First purposes. The Department of Government Efficiency that Trump created by executive order could also seek cuts in development aid.
The End of the Beginning of the End
Even after the executive orders issued in the first week of Trump's second presidency, the scope and scale of the Trump administration's impact on U.S. foreign policy on global health will increase. For example, the administration wants to overhaul domestic policies through a Make America Healthy Again agenda, which includes the promise in Trump's inaugural address to end the "chronic disease epidemic." What happens with that agenda will inform the always important domestic sources of U.S. foreign policy.
The scope and scale of the Trump administration's impact on U.S. foreign policy on global health will increase
The transformation of U.S. foreign policy on global health also confronts other challenges that will demand attention, including the threat of an avian influenza pandemic, the security of pharmaceutical supply chains, Chinese and Russian efforts to gain geopolitical advantages through health assistance, and ongoing concerns about biosecurity amid biotechnological advances aided by artificial intelligence.
Other priorities for Trump will make U.S. foreign policy on global health more diplomatically difficult and less politically important, such as raising tariffs on adversaries and allies, resolving the Ukraine war, stabilizing the Middle East, confronting China's global ambitions, and eyeing territorial expansion (for example, by reclaiming the Panama Canal and annexing Greenland).
Given its power, what the United States does has consequences for how countries around the world behave. Whether other nations can or want to limit the damage that U.S. withdrawal does to the WHO and global health multilateralism is not clear. Similarly, how states respond to the Trump administration's rejection of climate science and its aggressive fossil-fuel agenda will determine the fate of climate diplomacy for the foreseeable future.
In the story of U.S. foreign policy on global health, January 28, 2003—the day President George W. Bush stunned the world by creating PEPFAR—marks the start of decades of sustained, bipartisan, and consequential U.S. global health leadership. January 20, 2025—the day of Trump's second inauguration—signals the beginning of the end of that leadership. Trump and his team believe they have a better approach and are not mourning what is passing into history. The days and years ahead will pass judgment on that belief.
