A . Multilateral Engagement through International Organizations

The United States has long held a prominent role in the global health policy architecture under the UN, with the U.S. government central to the establishment and development of the World Health Organization (WHO). Arising out of U.S. leadership in the 1902 creation of the first regional health organization in the Americas, the United States would draw from the Pan American Sanitary Bureau to establish multilateral health governance under the UN.Reference Cueto¹ At the end of World War II, the United States hosted the International Health Conference that adopted the WHO Constitution, holding preeminent influence over WHO’s programming in its early years.Reference Hilleboe² In line with U.S. development funding to build a healthier world out of the destruction of World War II, the United States has looked to global health policy through WHO governance to alleviate human suffering and advance U.S. foreign policy interests.Reference Quimby³

From the very start of this new multilateral system for global health policy, however, the Cold War conflict between the United States and the Soviet Union would pose intractable threats to WHO legitimacy. With U.S. policymakers suspicious that WHO would seek to advance “socialized medicine,” the United States sought to employ its financial leverage to steer international health governance, pressing WHO to set a medically-focused agenda of “impact projects” to advance U.S. foreign policy interests in the Cold War.Reference Jacobson, Cox and Jacobson⁴ This early U.S. influence would lead Soviet states to abandon WHO membership for several years, with these withdrawals challenging the WHO promise of apolitical cooperation for health.Reference Allen⁵ Scholars lamented during this period that “in an era of cold war politics … public health has come to be subjected to cold war rhetorics[,] and this politics of public health has come to be centered on the international organization which was specifically created to promote international cooperation.”Reference Osakwe⁶

U.S. global health priorities continued to evolve following the end of the Cold War, impacting an expanding global health landscape. With a weakening of WHO governance amid the rise of new global health actors, the global health architecture began to shift toward greater U.S. influence in the 21st Century, with commentators increasingly noting that “the U.S. domestic agenda is driving the global agenda.”Reference Kickbusch⁷ The United States came to provide critical support for public-private partnerships in global health, as seen in U.S. leadership in 2000 to establish the Global Alliance for Vaccines and Immunization (now Gavi, the Vaccine Alliance).Reference Nossal⁸ Under a post-9/11 security paradigm, the United States sought to refocus on global health through the lens of national security, decreasing U.S. willingness to delegate health authority to international organizations.Reference Fidler⁹ Looking beyond WHO, the United States worked with other high-income nations to create the Global Fund to Fight AIDS, Tuberculosis and Malaria in 2002, making it clear that the United States was moving to create parallel governance institutions over which it would have greater control.Reference Brown, Cueto and Fee¹⁰ Through these new institutions, the United States looked to bypass established multilateral organizations through an expansion of its bilateral health assistance.

B . Bilateral Assistance as Central to Foreign Policy

As the largest bilateral donor for global health (albeit not the largest relative to gross domestic product), bilateral foreign health assistance has become an anchor of U.S. soft power – furthering U.S. global health leadership in a post-Cold War world. The United States has come to prefer bilateral assistance over multilateral collaborations, with bilateral assistance allowing for fewer negotiating parties and greater leverage for U.S. negotiators in setting global health policy.Reference McKeown¹¹ Where once this bilateral assistance was defined by uncoordinated medical approaches to select high-profile diseases, the United States has steadily shifted toward coordinated foreign assistance to support government health systems.¹²

U.S. bilateral health assistance has long outpaced support for multilateral health governance. Even as the United States worked with other nations to establish WHO governance following World War II, the U.S. government continued to pursue bilateral health assistance to:

1. (a) Western European governments under the Marshall Plan, with health projects established on an emergency basis;

2. (b) Latin American republics through the Pan American Sanitary Bureau, supporting governments throughout the Western hemisphere; and

3. (c) “developing states” under President Truman’s 1949 “Point IV Program,” providing technical health assistance as a fundamental role of U.S. foreign policy.Reference Russell¹³

This U.S. assistance was grounded in the early years of the Cold War in the containment of communism, advancing public health with “the open recognition, as a basis for national action, of the fact that communism breeds on filth, disease, and human misery.”Reference van Zile Hyde¹⁴ Framing health diplomacy to combat the “unsatisfactory living conditions on which Communism feeds,” U.S. foreign assistance would seek to influence minds as much as bodies — focusing on highly visible medical interventions as a means of “quieting unrest” in regions susceptible to communist influence.Reference Thorp¹⁵

Extended by the U.S. State Department, the 1961 establishment of the United States Agency for International Development (USAID) galvanized foreign assistance for public health, administering technical and economic assistance to develop institutions for health in low- and middle-income countries (LMICs).Reference Bristol¹⁶ USAID would be supported by the U.S. Public Health Service, the National Institutes of Health, the Centers for Disease Control and Prevention, and other government organizations seeking to advance international health initiatives under U.S. policy. The creation of these overlapping institutions for bilateral health assistance demonstrated a commitment to investing in health systems in LMICs, even as the focus of this assistance shifted from resource transfer to technology transfer.Reference Morefield¹⁷ To carry out this work throughout the world, such bilateral assistance has assumed responsibility for a number of foreign policy initiatives, retaining global health authority despite increasing congressional oversight and political influence.

A . Politicizing Global Health

Despite rising U.S. support for global health policy through the 1970s,Reference Bourne¹⁸ the 1980 election of President Reagan — and with it, the advancement of neoliberal economic policies and opposition to WHO multilateral initiatives — would challenge global health governance.Reference Mingst, Karns and Mingst¹⁹ Portending this growing politicization of global health, the Reagan Administration first attacked WHO’s regulation of commercial determinants of health, with the United States becoming the lone dissenting voice in opposition to the 1981 WHO International Code of Marketing of Breastmilk Substitutes, as the U.S. government sought to undermine a global health policy to promote breastfeeding and regulate formula corporations to protect infant health.Reference Starrels²⁰ This clash between the Reagan Administration’s pursuit of neoliberal economic policy and WHO’s focus on global health equity drove the continuing politicization of WHO’s health objectives.

Reducing financial support for WHO governance, the U.S. government permanently shifted WHO’s budgetary foundations. WHO’s budget had been structured since its founding by obligatory contributions from its member states (with each state’s contribution determined through an established UN formula)Reference Vaughan, Mogedal, Kruse, Lee, Walt and de Wilde²¹ alongside “extrabudgetary funding” for specific priorities (from governmental and nongovernmental sources, including UN agencies).Reference Walt²² Under the Reagan Administration, however, the United States withheld its assessed biannual contribution to the WHO budget, criticizing the organization for its alleged lack of transparency and limitation of free enterprise in the health sector.Reference Cueto, Brown and Fee²³ This politicization of WHO’s health programming led to an increased WHO reliance on extrabudgetary funding that has persisted to the current day, such that assessed member state contributions now make up less than 20% of WHO’s overall budget.²⁴

Beyond WHO’s shift toward extrabudgetary funding, the Reagan Administration’s politicization of global health resulted in increasing attacks on sexual and reproductive health and rights. Reflecting conservative religious ideologies that opposed gender equity, contraception, and abortion, the Reagan Administration abandoned domestic birth control programs and global family planning initiatives.²⁵ This opposition extended to lesbian, gay, bisexual, and transgender (LGBT) rights. Even as HIV/AIDS spread exponentially through the early 1980s, the Reagan Administration refused to address this rising threat to marginalized populations, leading to delayed and insufficient support for initiatives to address HIV/AIDS — at home and throughout the world.Reference Richert²⁶ This politicization of sexual and reproductive health culminated at the 1984 International Conference on Population in Mexico City, where the United States declared that all bilateral aid to non-governmental organizations (NGOs) could not be used for any abortion-related activity.²⁷ This policy, now known as the “Mexico City Policy” or the “Global Gag Rule,” has come to be rescinded and reimplemented ever since amid changes in Democratic and Republican presidential administrations — with every new Democratic president rescinding it and every new Republic president reinstating it.Reference Pugh, Desai, Ferguson, Stöckl and Heidari²⁸

In an early effort to reengage with global health, the Clinton Administration immediately revoked the Global Gag Rule and rapidly doubled spending on HIV/AIDS research, prevention, and treatment. The United States sought renewed leadership in multilateral health governance, playing a major role in: accelerating the HIV/AIDS response through the 1994 creation of the Joint United Nations Programme on HIV/AIDS (UNAIDS); engaging in the Fourth World Conference on Women in 1995 and strengthening the United Nations Population Fund (UNFPA); and supporting a united front against climate change through the 1997 Kyoto Protocol.²⁹ Supporting WHO governance, the Clinton Administration would advance global health policy through revisions to the International Health Regulations (IHR) and negotiations to develop the Framework Convention on Tobacco Control (FCTC).Reference Fidler³⁰ As a foundation for continuing bilateral health initiatives, the U.S. Leadership and Investment in Fighting an Epidemic (LIFE) initiative was announced in 1999 to address HIV/AIDS in Africa and India. Yet despite this increasing financial support, the legacy of the neoliberal approach to health persisted. The U.S. government continued to address health as a means to economic development (rather than an end unto itself), with this neoliberal “health for growth” model elevating health, nutrition, and population funding under the World Bank and strengthening pharmaceutical patent protections under the World Trade Organization (WTO).Reference Petchesky³¹ In bringing together the entire UN to address economic development at the start of the 21st Century, the United States provided crucial leadership in the adoption of the Millennium Development Goals (MDGs), which set key global health targets for the reduction of maternal and infant mortality, the prevention of HIV infection, and the eradication of poverty and hunger.

B . Global Health Divides Political Parties

However, the terrorist attacks of September 11, 2001 would reshape U.S. engagement in global health governance, as the United States moved to address global health through the lens of national security. Following years of viewing global health as a humanitarian imperative, the 9/11 attacks (and anthrax attacks in the days that followed) upended global health engagement under the Bush Administration, propelling public health into security debates.Reference Khan³² Global health advocates drew from this post-9/11 security paradigm to argue that public health challenges amounted to a threat to “health security,” a rhetorical reframing intended to conjure up national security fears in response to public health threats.Reference Brower and Chalk³³ Thus, instead of recognizing AIDS as a threat to global health and human rights, the U.S. government worked within the UN Security Council to highlight the effects of HIV/AIDS on international peace and security.Reference Sekalala, Williams and Meier³⁴

Despite this securitization of global health, the 2003 establishment of the President’s Emergency Plan for AIDS Relief (PEPFAR) set up the U.S. State Department’s Office of the Global AIDS Coordinator as the principal mechanism of U.S. global health funding. The launch of PEPFAR represented an unprecedented commitment to scaling up programs for the care and treatment of HIV — an increase in U.S. government spending to rival any other national effort in global health.Reference Emanuel³⁵ Yet, PEPFAR’s early reliance on medical services for a single disease led to HIV/AIDS programs that “crowded out” public health systems and constrained national health policies in LMICs.Reference Marchal, Cavalli and Kegels³⁶ The United States continued to advance efforts to address HIV, malaria and other high profile diseases, but these fragmented and shifting U.S. efforts were criticized by scholars and advocates for their lack of coordination across government agencies, lack of attention to health systems, and lack of strategy for foreign assistance.Reference Gostin³⁷

Responding to these critiques, the Obama Administration moved to refocus foreign assistance for global health. With growing calls for U.S. global health leadership — a call that grew stronger as the 2008 global financial crisis undermined public health progressReference Garrett³⁸ — the Obama Administration’s Global Health Initiative (GHI) advanced a comprehensive strategy to coordinate all U.S. global health initiatives, reshaping foreign health assistance across U.S. agencies, programs, and partners.Reference Morison³⁹ This initiative would seek to frame how the entire U.S. government implemented its resources across global health activities and engaged with international partners and recipient countries to strengthen health systems.Reference Meier⁴⁰ Even as the GHI was abandoned in President Obama’s second term, the United States would continue to uphold global health governance, with the U.S. government supporting WHO amid early challenges in the 2014-2016 Ebola response in West Africa.Reference Kolker⁴¹ With WHO facing continuing limitations in infectious disease governance under the IHR, the U.S. government would join with other governments in 2014 to establish the Global Health Security Agenda (GHSA), working outside of WHO to support national governments to promote global health security.Reference Katz, Sorrell, Kornblet and Fischer⁴² The United States was developing new partnerships to respond to globalized health challenges; however, the 2016 U.S. Election would lead to profound transitions in U.S. direction and leadership in global health policy.

C. Global Health as Determining Factor in the 2020 Elections

The Trump Administration came to office set upon reducing U.S. engagement in international affairs, and this rising isolationism in U.S. policy would prove costly to global health. As with previous Republican administrations, one of President Trump’s first official decisions was resurrecting the “Mexico City Policy,” prohibiting U.S. funding to NGOs engaged in abortion-related activities, but President Trump went a step further than his Republican predecessors — expanding the policy from abortion-related services to all family planning servicesReference Singh and Karim⁴³ and then withholding funding for UNFPA.Reference Dyer⁴⁴ Seeking an “America First” agenda, the Trump Administration rejected a range of international policies and organizations that were seen to limit U.S. actions, as the United States withdrew from several UN agencies and from the Paris Climate Agreement.Reference Jotzo, Depledge and Winkler⁴⁵ This sudden U.S. shift was abetted by the rise of right-wing populist nationalism across high-income nations, as nations that once collaborated to develop global health policy increasingly neglected public health, restricted human rights, and opposed global governance.Reference Gostin, Constantin, Meier, Gostin and Meier⁴⁶ In the United States, the Trump Administration made substantial cuts to global health funding, in both multilateral and bilateral support,Reference Micah, Zlavog, Friedman, Reynolds, Chapin, Schneider and Dieleman⁴⁷ and this sharp U.S. pullback in global health support would undermine efforts to respond to rising global health challenges.

On March 13, 2020, President Trump declared the COVID-19 outbreak a national emergency; however, the Administration quickly politicized the pandemic, as Administration officials interfered in public health decision-making in ways that destabilized the pandemic response at home and abroad.Reference Oberlander⁴⁸ The U.S. government ignored WHO guidance and rapidly imposed travel restrictions against Asian nations — avoiding public health justifications and stoking xenophobic divisions.Reference Meier⁴⁹ Following Trump Administration accusations that WHO was biased toward China in the COVID-19 response, the administration halted funding to WHO in April 2020 and later sought to withdraw from WHO membership entirely.Reference Williams, Kestenbaum and Meier⁵⁰ As the United States disengaged from WHO governance amid an escalating pandemic threat, other nations and multilateral organizations rallied together to form the COVID-19 Vaccines Global Access (COVAX) facility (co-led by the WHO, Gavi, the Vaccine Alliance, and the Coalition for Epidemic Preparedness Innovations).Reference McAdams, McDade, Ogbuoji, Johnson, Dixit and Yamey⁵¹ WHO pleaded with the nations for “global solidarity” in the pandemic response, but the U.S. government adopted a continuing isolationist response.Reference Gostin, Moon and Meier⁵² Instead of joining global efforts to develop and distribute a COVID-19 vaccine, the administration announced Operation Warp Speed, which provided U.S. funding to individual pharmaceutical corporations — to provide vaccines specific to U.S. needs.Reference Tanne⁵³

With the COVID-19 pandemic exposing the limitations of these nationalist approaches to global health, then candidate Biden campaigned on reversing Trump Administration decisions: returning to WHO membership, repealing the Global Gag Rule, and rejoining the Paris Climate Agreement.Reference Jaffe⁵⁴ Health policy concerns would prove decisive in the 2020 Presidential Election.Reference Clarke, Stewart and Ho⁵⁵ On President Biden’s first day in office, he wrote to the UN Secretary-General to retract his predecessor’s decision to withdraw from WHO and reaffirm U.S. financial commitments to WHO.Reference Jha⁵⁶ President Biden announced shortly thereafter that the United States would join COVAX and contribute to global efforts to distribute COVID-19 vaccines.Reference Puyvallée and Storeng⁵⁷ (The United States committed to donating more than 1.2 million COVID-19 vaccines in 2022, launching the U.S. Initiative for Global Vaccine Access to contribute to theglobal goal of vaccinating 70% of the world against COVID-19 in 2022.⁵⁸) With U.S. leadership in global health diminished, the Biden/Harris Administration pursued bipartisan policy initiatives to improve health systems, pandemic preparedness, and global health diplomacy, including through the Inflation Reduction Act (IRA) to promote clean energy, the reauthorization of PEPFAR for HIV/AIDS treatment, and the Pandemic and All-Hazards Preparedness Act (PAPHA).Reference Morrison and Simoneau⁵⁹ The U.S. government has sought to improve pandemic preparedness capacity multilaterally by strengthening global health governance — under amendments to the IHR, a focus on “legal preparedness” under the GHSA, and the continuing negotiation of a new WHO Pandemic Agreement.Reference Meier, Habibi and Gostin⁶⁰ The Biden/Harris Administration has sought to mend ties in global governance and reestablish the U.S. as a leader in global health; however, the 2024 U.S. Elections will be pivotal to determining whether this global engagement continues — or if the United States will revert to isolationist approaches to global challenges.

A . Global Governance

Amid continuing attacks on the rule of law and integrity of elections, there remain concerns about continuing U.S. backsliding in governance away from democracy. This rightward populist shift extends beyond the United States, with rising right-wing governments undermining democratic principles and shifting toward autocratic governance.Reference Slipowitz and Repucci⁶¹ With these authoritarian governments increasingly seeking to undermine the rules-based (and long U.S.-supported) global order, the 2024 U.S. Elections will determine the continuing advancement of the global health governance system that has brought nations together since the end of World War II – within WHO and across the UN.

B . Health Funding

The United States has remained the largest government donor in global health, but it is unclear whether that financial support will continue following the 2024 Elections. Although the U.S. Congress has long supported global health assistance and prevented cuts to global health funding across political parties, as seen in bipartisan efforts in 2018 to prevent the elimination of NIH’s Fogarty International Center,Reference Drain⁶² public health initiatives have increasingly come to be associated with the Democratic party.⁶³ Where U.S. spending on global health has become politically polarized (as seen most recently in Republican opposition to renewing funding for PEPFAR), this election will determine continuing financial support for global health.

C . Sexual and Reproductive Health

U.S. political parties have presented divergent ideologies regarding human rights in the context of health, with clear divisions on the promotion or restriction of sexual and reproductive health and rights. Republican ideologies have become grounded in religious beliefs regarding women’s sexual and reproductive lives and “traditional” gender roles, whereas Democratic ideologies are strongly aligned with a human right to health, gender equality, and individual liberty in accessing sexual and reproductive health services.Reference Palley and Palley⁶⁴ These differences have manifested themselves in global health debates on abortion care, same-sex marriage, and gender identity — with the coming Administration making crucial decisions on the Mexico City Policy, HIV/AIDS policies, and gender-affirming care policies that will reverberate throughout the world.

D . Corporate Regulations

U.S. corporate regulations have long divided the Republican and Democratic parties; however, the coming years present the opportunity to create lasting impact in the international regulation of tobacco, food, and pharmaceuticals. The Biden/Harris Administration has committed to limit international tobacco smuggling (if missing opportunities to regulate nicotine and ban menthol), address global food insecurity (through the United Nations and bilateral humanitarian assistance); and lower the cost of prescription drugs (supporting global access to essential medicines). By contrast, the Trump Administration long sided with multinational corporate interests in opposition to international regulation, including efforts to remove health warnings from food labels, undermine implementation of the International Code of Marketing of Breastmilk Substitutes, and limit corporate accountability for human rights violations.Reference Collins, Rothe and Akande⁶⁵

E . Tax Equity

One of the most important, if under-used, approaches to mobilizing financing for global public goods for health — from controlling pandemics to preventing antimicrobial resistance — has been progressive taxation. Where nations have come together to negotiate a minimum income tax on the wealthiest individuals and transnational corporations,Reference Zucman⁶⁶ it will be crucial that this tax policy reflects a global agreement, preventing tax avoidance across nations that has benefited powerful interests at the expense of public goods.Reference Agénor⁶⁷ However, this focus on global tax equity has divided U.S. political parties. While opposing a global tax on wealthy individulals, President Biden has proposed a “Billionaire Minimum Income Tax,”Reference Kim⁶⁸ but this proposal has met with opposition from congressional Republicans and President Trump, who have pledged to reduce taxes on the wealthy.

F . Humanitarian Challenges

Humanitarian crises are on the rise, with natural disasters, armed conflicts, and population displacements quickly leading to the breakdown of health systems, deterioration of health conditions, and transmission of infectious diseases. Where health responses to these crises are governed by international humanitarian law (IHL), both political parties have shown waning respect for IHL commitments, as seen in neglect of international law in response to attacks in Ukraine, Sudan, Gaza, and the Democratic Republic of Congo. ^{Reference Gostin and Goodwin69} While there is growing global awareness of these violations of IHL, there remain few measures of U.S. accountability for these violations, with both parties seen to put geopolitical priorities above international law, limiting support for humanitarian needs and stymieing action within international organizations.

G . Climate Change

Climate change is seen as the most pressing global threat of the 21st century, with international coordination critical to addressing the climate crisis and resulting health harms. ^{Reference Watts70} The United States had begun to take steps to reduce carbon emissions to mitigate this cataclysmic threat when the Trump Administration stepped back from this global commitment, reversing environmental protections, withdrawing from the Paris Agreement, and challenging climate science. Reengaging with this global challenge, the Biden/Harris Administration has taken renewed action by reinstating the U.S. commitment to the Paris Agreement, transitioning to renewable energy under the Inflation Reduction Act, and supporting LMICs in adapting to rising temperatures, but the outcome of the 2024 Election will determine how the United States continues to reduce emissions domestically and coordinate efforts globally.Reference Tollefson, Gilbert, Kozlov and Lenharo⁷¹