America First, Global Health Last

America First, Global Health Last

The International Cost of a Public Health Retreat

The PEPFAR Shutdown

On January 24, 2025—four days into the administration’s second term—the State Department froze all foreign aid¹, including the President’s Emergency Plan for AIDS Relief (PEPFAR). For context: PEPFAR is credited with saving 26 million lives since 2003². It was created by a Republican president in 2003 and maintained with bipartisan support through three subsequent administrations.

Twenty million people worldwide rely on PEPFAR for HIV treatment³. On January 24, those people were cut off.

What Happened Next

Within days, documented impacts emerged:

• Clinics across Africa, Asia, and Latin America closed⁴
• Antiretroviral medication stockouts began⁵
• Healthcare workers were laid off mid-shift⁶
• 220,000 patients who visit PEPFAR-supported clinics daily were turned away⁷

In Mozambique, HIV testing dropped from approximately 30,000 tests per month to near zero immediately after the funding freeze⁸. In Johannesburg’s APACE program, the number of people tested for HIV fell by 75% within weeks⁹.

People began rationing their HIV medications—taking pills every other day instead of daily¹⁰. This creates drug-resistant HIV strains¹¹.

The Human Cost (Documented)

A limited waiver was issued February 1 to exempt “life-saving” services¹², but implementation has been incomplete. As of September 2025, UNAIDS reports:

• 40% of 70 UNAIDS country offices witnessed end to community-led services¹³
• 30% reported international NGO services stopped¹⁴
• Medication stockouts in multiple countries¹⁵
• Staffing cuts at HIV/AIDS clinics¹⁶
• “Rising levels of stigma, discrimination and mortality rates”¹⁷

USAID—which administered 60% of PEPFAR’s bilateral funding¹⁸—was permanently dismantled in early 2025. Most USAID employees were placed on leave or dismissed¹⁹. Without USAID staff, even programs with waivers couldn’t restart due to lack of administrative capacity²⁰.

The Projected Death Toll

Multiple peer-reviewed studies have modeled the impact of PEPFAR disruption:

Conservative Estimate (90-day freeze):

• 60,000-74,000 excess HIV deaths by 2030²¹
• Based on proportional treatment disruption model
• Assumes services restart after initial freeze

Realistic Estimate (system collapse):

• 770,000 to 2.9 million additional deaths by 2030²²
• Accounts for cascading system failures
• Includes loss of testing, prevention, and treatment infrastructure

New Infections:

• 71,500 to 10.8 million new HIV infections by 2030²³
• Depends on success of mitigation efforts
• Drug-resistant strains already emerging²⁴

A Boston University research team created a real-time Impact Counter tracking projected deaths. As of their methodology paper, the counter projected 176,000+ additional HIV deaths if funding is not restored by end of 2025²⁵.

The Money

PEPFAR’s FY2024 budget: $6.5 billion²⁶ Current administration’s FY2026 proposal: $4.6 billion ($1.9 billion cut)²⁷

For comparison:

• $1.9 billion = 95 elementary schools²⁸
• $1.9 billion = food for 847,000 Americans for one year²⁹
• $1.9 billion = 0.03% of the $6.75 trillion federal budget³⁰

Historical Comparison

2003-2009 (Previous Republican Administration):

• Created PEPFAR with $15 billion initial commitment³¹
• Saved an estimated 1.1 million lives in first 5 years³²
• Built bilateral relationships through health diplomacy
• Established U.S. as global leader in HIV/AIDS response

2009-2017 (Previous Democratic Administration):

• Maintained and expanded PEPFAR³³
• Budget grew from $5.6 billion to $6.8 billion³⁴
• Supported 11.5 million people on antiretroviral therapy by 2016³⁵
• Zero disruptions to medication supply chains

2021-2025 (Previous Democratic Administration):

• Maintained PEPFAR at $4.7-4.85 billion³⁶
• Supported 20.5 million people on treatment³⁷
• Zero disruptions to medication supply
• Strengthened pandemic preparedness infrastructure

2025-Present (Current Administration):

• Froze all PEPFAR funding January 24³⁸
• Dismantled USAID permanently³⁹
• Proposed $1.9 billion cut⁴⁰
• Documented clinic closures and medication stockouts within 72 hours⁴¹
• 83% of USAID global contracts canceled⁴²

The WHO Withdrawal

On the administration’s first day, an executive order was signed withdrawing from the World Health Organization⁴³. This takes effect January 20, 2026 (one-year notice required by treaty).

What We Lost

The United States contributed approximately 15.6% of WHO’s $6.83 billion budget—roughly $1 billion annually⁴⁴.

That’s the cost of 50 elementary schools.

WHO coordinates:

• Global influenza surveillance (critical for annual vaccine development)⁴⁵
• Disease outbreak response⁴⁶
• International health regulations⁴⁷
• Pandemic preparedness⁴⁸
• Climate and health programs⁴⁹

The CDC was ordered to immediately cease all collaboration with WHO⁵⁰. All formal communications stopped January 20, 2025.

Real-World Impact

When CDC stopped collaborating with WHO:

• Annual flu vaccine recommendations were made without consulting WHO’s global network⁵¹
• U.S. lost access to real-time international disease surveillance⁵²
• Global flu tracking systems now operate without U.S. input⁵³
• Dengue outbreaks in Americas reached 12.6 million cases (triple previous year) with reduced U.S. coordination⁵⁴

For context: Approximately 30,000 elderly Americans die from flu complications annually⁵⁵. Effective flu vaccines require global surveillance of circulating strains—exactly what WHO coordinates.

Johns Hopkins School of Public Health noted that the withdrawal “will put the country and world at heightened risk of public health crises”⁵⁶ and that pandemic preparedness efforts would be severely hampered⁵⁷.

The Budget Math

Total international health cuts (documented and proposed):

PEPFAR reduction: $1.9 billion WHO contribution: $1.0 billion Global Health Security cuts: ~$300 million⁵⁸ Total: ~$3.2 billion

This equals:

• 160 elementary schools
• 1.4 million Americans fed for one year
• 0.05% of the federal budget
• 2.3 days of Pentagon spending ($456 billion annually)⁵⁹

What Other Administrations Did

2014 Ebola Response (Previous Democratic Administration):

• Deployed 3,000 U.S. military personnel to West Africa⁶⁰
• CDC sent 1,400 responders⁶¹
• Spent $5.4 billion on emergency response⁶²
• Zero U.S. deaths from Ebola transmission
• Contained outbreak before global pandemic

2003 HIV/AIDS Response (Previous Republican Administration):

• Created PEPFAR with bipartisan support⁶³
• Made U.S. the global leader in HIV/AIDS response
• Estimated 1.1 million lives saved in first 5 years⁶⁴
• Built lasting diplomatic relationships through health cooperation

2021-2025 COVID-19 Response (Previous Democratic Administration):

• Maintained WHO partnership⁶⁵
• Sustained PEPFAR funding⁶⁶
• Provided COVID-19 vaccines to 115 countries⁶⁷
• Strengthened global health security frameworks

2025 Response (Current Administration):

• Withdrew from WHO on day one⁶⁸
• Froze PEPFAR funding on day four⁶⁹
• Dismantled USAID⁷⁰
• Cut $3.2 billion from global health⁷¹
• Documented clinic closures and medication stockouts within 72 hours⁷²

The Trust Deficit

Beyond dollars, international health infrastructure depends on trust. When the U.S. cut off PEPFAR mid-treatment:

• Clinics scrambled to inform patients⁷³
• Healthcare workers lost jobs without notice⁷⁴
• Partner countries questioned U.S. commitment⁷⁵
• Ongoing research projects were abandoned mid-study⁷⁶

A South African health official described it as “being pushed off a cliff instead of a careful handover”⁷⁷.

The International AIDS Society stated: “These are not mere programs to be switched on and off by decree. This will be a bloodbath. Millions will suffer as a result of these actions, and global health—and the very notion of solidarity—will be unrecognizable.”⁷⁸

South Africa: A Case Study

South Africa, with 8 million people living with HIV⁷⁹, received $462 million from PEPFAR in FY2023⁸⁰—the largest recipient globally. The country already pays for 83% of its HIV/AIDS efforts⁸¹, and PEPFAR was supporting a planned 5-year transition to full domestic funding⁸².

Research published in Annals of Internal Medicine projected that if PEPFAR funding is not replaced, South Africa could experience⁸³:

• 565,000 additional new HIV infections by 2034
• 601,000 more deaths from HIV by 2034
• $1.7 billion in extra healthcare costs

South African researchers noted: “Instead of a careful handover, we’re being pushed off a cliff”⁸⁴.

The Mechanism of Harm

PEPFAR doesn’t just provide medication. The program supports:

• HIV testing and counseling⁸⁵
• Prevention programs (including PrEP)⁸⁶
• Mother-to-child transmission prevention⁸⁷
• Laboratory infrastructure⁸⁸
• Health information systems⁸⁹
• Healthcare worker training⁹⁰
• Supply chain logistics⁹¹

When funding stopped, these interconnected systems collapsed. In Mozambique, one researcher noted: “If USAID funds 50 percent of a country’s total budget for HIV prevention and treatment, that doesn’t mean half of the HIV programs continue running. That funding could have supported the IT systems or staff members for the entire program.”⁹²

What We’re Trading

The $3.2 billion in international health cuts could:

• Build 160 elementary schools in America
• Feed 1.4 million Americans for a year
• Represent 2.3 days of Pentagon spending
• Equal 0.05% of the federal budget
• Cost less than Americans spend on Valentine’s Day gifts ($3.9 billion annually)⁹³

In exchange:

• 20 million people lost HIV treatment access
• Global disease surveillance networks weakened
• U.S. withdrew from international health leadership
• Documented medication stockouts and clinic closures
• Partner countries lost trust in U.S. commitments
• 60,000-2.9 million projected deaths by 2030

The Security Argument

Global health isn’t charity—it’s national security. Diseases don’t respect borders. When HIV becomes drug-resistant in Tanzania due to medication rationing, those resistant strains can reach New York within months⁹⁴.

Previous Republican and Democratic administrations understood this. PEPFAR was created explicitly as a national security investment⁹⁵. The 2014 Ebola response deployed thousands to West Africa to prevent the disease reaching America⁹⁶.

The World Health Organization serves as the early warning system for global health threats. The 2003 SARS outbreak, 2009 H1N1 pandemic, 2014 Ebola epidemic, and 2020 COVID-19 pandemic all benefited from WHO’s coordination role⁹⁷.

The current administration dismantled these protections for the cost of 160 elementary schools—in a nation with 130,000 K-12 schools⁹⁸.

Congressional Response

Congress has pushed back on some cuts. In July 2025, Congress voted down a proposed additional $400 million rescission from PEPFAR⁹⁹. However, the broader funding freeze and USAID dissolution have proceeded.

Twenty-five states and the District of Columbia sued the federal government over PEPFAR delays¹⁰⁰. Two federal judges ruled in October 2025 that the administration had to continue payments, but the federal government appealed¹⁰¹.

By The Numbers

Every dollar cut from global health represents specific capabilities:

• PEPFAR: 20 million people on HIV treatment
• WHO: Global disease surveillance for 195 countries
• USAID: Implementation capacity in 50+ countries
• Global Health Security: Pandemic preparedness networks

We traded these for $3.2 billion—0.05% of federal spending.

The Long-Term Cost

The administration’s stated savings of $3.2 billion must be weighed against:

• Projected 60,000-2.9 million excess deaths by 2030¹⁰²
• Emergence of drug-resistant HIV strains¹⁰³
• Weakened pandemic preparedness¹⁰⁴
• Loss of U.S. diplomatic influence¹⁰⁵
• Damaged relationships with partner countries¹⁰⁶
• Potential for diseases to reach U.S. borders¹⁰⁷

The economic cost of the COVID-19 pandemic in the U.S. alone was approximately $15 trillion¹⁰⁸. That’s 4,688 times larger than the $3.2 billion in global health cuts.

Previous pandemics were contained before reaching pandemic proportions through the very international health infrastructure now being dismantled: SARS (2003), H1N1 (2009), Ebola (2014), and Zika (2016) all benefited from coordinated global response¹⁰⁹.

Moving Forward

These are documented facts:

• $3.2 billion cut from global health programs
• 20 million people lost HIV treatment access
• WHO membership terminated
• USAID permanently dismantled
• Documented clinic closures within 72 hours
• Medication stockouts across multiple countries
• 60,000-2.9 million projected deaths by 2030

The question isn’t whether this happened. The question is whether Americans believe saving 160 elementary schools’ worth of federal spending—representing 0.05% of the budget—is worth abandoning global health leadership built over 75 years.

The answer will determine whether the next pandemic—which public health experts say is inevitable¹¹⁰—finds America prepared or isolated.

When that pandemic arrives, we will pay far more than $3.2 billion to contain it. COVID-19 taught us that lesson at a cost of $15 trillion and 1.2 million American lives¹¹¹.

The question is whether we learned it.

References