Ted Brown| Professor Emeritus of History and Public Health Sciences, University of Rochester
On January 20, 2025, the day on which he was inaugurated as 47th President of the United States, Donald J. Trump signed an Executive Order “Withdrawing the United States from the World Health Organization.” The Executive Order begins with a list of the Trump Administration’s grievances with the WHO: it allegedly mishandled the COVID-19 pandemic; failed to adopt urgently needed reforms; failed to achieve independence from the political influence of WHO member states; and exacted unfairly onerous membership payments from the United States. Justified by these grievances, the Executive Order announced several immediate actions: it affirmed the U.S.’s intention to withdraw from WHO and instructed the U.S. Secretary of State immediately to inform the Secretary General of the United Nations and the Director General of WHO of the withdrawal; it paused the future transfer of United States Government funds, support or resources to WHO and recalled and reassigned United States Government personnel or contractors working in any capacity with the WHO; ceased U.S. participation in negotiations on the WHO Pandemic Agreement and the amendments to the International Health Regulations, declared that any such agreement and amendments will have no binding force on the United States, and instructed the White House Office of Pandemic Preparedness and Response Policy to review, rescind, and replace the 2024 U.S. Global Health Security Strategy as soon as possible. The Executive Order also tasked the U.S. Secretary of State and the Director of the Office of Management and Budget to “identify credible and transparent United States and international partners to assume necessary activities previously undertaken by the WHO” but gave no indication how or with whom this was to be done.
Although President Trump’s Executive Order created a great deal of consternation in the international and global health community, much still remains murky about what it really means and how it would be implemented. Trump’s intent to withdraw the U.S. from WHO is clear, and the UN quickly acknowledged that intent, presumably to be effective January 22, 2026. But even that issue is not straightforward. The stipulations surrounding withdrawal specify that any member state seeking to withdraw from WHO must first pay all assessed dues, including arrears, before attaining the right to withdraw. The United States hasn’t yet paid its assessed contribution for 2024, much less for 2025, and these matters must be addressed first to meet the requirements of international law. In addition, the decision to withdraw from WHO is very contested within domestic U.S. politics. Leading American political, legal, and health policy authorities note that the U.S. decision to join WHO was made in 1948 by an Act of Congress passed by both houses and signed by President Harry Truman as Public Law 643 and, according to these same authorities, would thus require an Act of Congress signed by the President, not a Presidential Executive Order, to reverse that earlier decision. Similarly, assessed dues and arrears in assessed dues must be allocated by Congressional vote, not decided by the President or his Office of Management and Budget.
Even if political and fiscal matters were settled and the United States withdrew uncontestedly both membership and dues from WHO, ironically this would not mean that American funds would stop flowing to WHO. In fact, the vast majority would continue to flow because their source is “voluntary” as opposed to “assessed” (mandatory) contribution. Voluntary contributions have always been a large part of WHO budgeting and have become an increasingly large share of the budget, beginning in the 1980s and growing ever larger since. In 2022-2023, assessed contributions made up 12% of WHO’s budget while voluntary contributions made up 87%. For 2024-2025, the United States’ assessed contribution was $264 million and China’s was $181.00 million. The largest voluntary contributors for the 2022-2023 biennium were the Bill and Melinda Gates Foundation [$830 million], GAVI (the Vaccine Alliance whose members include UNICEF, the World Bank, vaccine manufacturers, and private sector partners) [$481 million], and Rotary International (a global service network whose principal international health goal is eradicating polio worldwide) [$177 million]. Voluntary contributions from the Gates Foundation, GAVI, Rotary International, and other donors continued at high levels in the 2024-2025 biennium. In addition to voluntary efforts in which American donors play major roles beyond the reach of the reach of the U.S. government, those donors also participated in a new WHO voluntary fundraising initiative which culminated in an event coinciding with the G20 leaders’ summit in Brazil in November 2024. WHO reports that it was able to raise an additional $3.8 billion in donor pledges through 2028. Also of great potential importance to the fiscal health of WHO despite the U.S.’s projected withholding of its assessed contribution was the decision by member states in 2022 to support an in-principle increase in assessed contributions for the 2024-2025 biennium. The first two blows inflicted by President Trump’s Executive Order could thus cause political distress and financial duress in WHO but would not likely prove fatal.
The third blow was the recall and reassignment of United States government personnel and contractors working with WHO. This recall applied primarily to the salaried employees of the Centers for Disease Control and Prevention (CDC), which issued a “stop-work memo” on January 27, 2025 applying to “all CDC staff engaging with WHO through technical working groups, coordinating centers, advisory boards, cooperative agreements or other means – in person or virtual.” CDC staff have long played major roles in WHO, whether in supervisory and leadership positions, in data and epidemiological intelligence analysis, and in field operations in various parts of the world, frequently in outbreak hotspots in Africa and elsewhere. In actual numbers, however, CDC salaried employees are a very small portion of WHO’s total professional workforce, approximately 30 out of 8,000 or more WHO employees. Those working at CDC “collaborating centers” in the United States would add to this total, but not in overwhelming numbers, and there are several private American universities like Yale, Stanford, Columbia, and others that are also WHO collaborating centers and will presumably not be affected by the CDC stop work order. Like the CDC personnel stop work order, this one may be a bit disruptive but not catastrophically so.
International health experts have, in fact, consistently argued that the United States would be the biggest loser if it withdrew CDC and other government-funded personnel from participation in WHO operations. The U.S. would lose access to massive amounts of international epidemic and endemic disease data and will no longer receive privileged updates on circulating pathogens, not least on influenza virus variants which are crucial in designing each year’s influenza vaccines. The Trump administration seems to be experiencing a slowly dawning recognition of the major downsides to this decision and on February 24, 2025 Helen Branswell reported in STAT that “CDC will be actively participating virtually at the WHO vaccine consultation meeting for the recommendation of viruses for 2025-2026 Northern Hemisphere vaccine this week.” There is also another major downside to the heavy-handed and ill-considered Trump administration withdrawal of CDC from WHO which could potentially have extremely dangerous and almost certainly unforeseen consequence but of which few seem publicly aware: loss of the United States’ key role in assuring global security in the oversight of the world’s residual stock of remaining smallpox virus now maintained in two highly secure facilities, one in the U.S. at the CDC in Atlanta and one in Russia at the Laboratory of the State Research Institute for Viral Preparations in Moscow. These two closely guarded and warily balanced repositories have provided a kind of “biological mutual deterrence,” but with the CDC gone as a “co-watchdog,” Russia could more easily use some of its viral stock to create lethal bioweapons with targeted smallpox virus, a circumstance the Trump administration very likely failed to consider as a consequence of ordering CDC to leave WHO.
The fourth blow inflicted by President Trump’s Executive Order was the immediate cessation of U.S. participation in negotiations on the WHO Pandemic Agreement and amendments to the International Health Regulations (IHR) and the declaration that any such agreement or amendments would have no binding force on the United States. In reality, this blow was rather slight because the United States had already been a foot-dragging and seemingly reluctant participant in the negotiations for some time. A fundamental tension hampered these discussions. High income countries, the United States most notably, strongly promoted data sharing, but low and middle income countries focused on the sharing of technology, vaccines, and pharmaceuticals with subventions or at reduced prices. A compromise seemed quite distant well before the Trump administration took charge, with equitable access to pandemic technologies as a major barrier to agreement. Already under the Biden administration, the U.S. protected the interests of its domestic pharmaceutical industry, and the transition to the Trump administration only reinforced this priority.
But if the United States would not acknowledge the International Health Regulations and follow its stipulations, how would it get access to crucial international epidemiological data? According to President Trump’s January 20th Executive Order, the U.S. Secretary of State and the Director of the Office of Management and Budget were tasked to “identify credible and transparent United States and International partners to assume necessary activities previously undertaken by the WHO.” Certain U.S. universities like Harvard and Johns Hopkins are obvious potential partners and among potential international partners the Pan American Health Organization (PAHO) would seem to be an obvious leading candidate. PAHO has developed considerable epidemiological data repositories and analytical capabilities, and the United States is an active and influential member of the organization. In fact, the organization was founded and led for many years by U.S. public health authorities and still maintains a major headquarters in Washington, D.C. But a significant complication, perhaps incompletely assessed by the Trump administration, is that PAHO is an integral part of the WHO, in fact, it is one of its six constituent regional offices known in official WHO language as the “American Regional Office of WHO” or “AMRO.”
By claiming to withdraw from WHO but making no such threat or effort to withdraw from AMRO, the Trump administration seems to have unknowingly backed into bizarre circumstances analogous to those of the post-World War I period when the United States refused to join the League of Nations Health Organization (LNHO) but at the same time remained active in the Office Internationale Hygiene Publique (OIHP) which had been founded before LNHO and in which the United States as a member nation and PAHO as a regional health organization were both active components. OIHP was responsible for maintaining and updating the IHR as they existed at the time, and the United States willingly supplied data and participated in negotiations on amendments to the IHR as needed while at the same abstaining from official participation in LNHO whose activities included innovations in the collection, analysis, and application of international epidemiological data. In addition, several outstanding American public health professionals worked for the LNHO as salaried employees or advisers, and a considerable part of the organization’s operating budget was provided by the Rockefeller Foundation, a major U.S. private philanthropy. The U.S.’s bizarrely conflictual arrangements with OIHP and LNHO were confusing, inefficient, and unsustainable and widely acknowledged as such at the time. Both organizations and their illogical competition collapsed with the advent of World War II and were replaced by the WHO in the postwar period, when the residual functions of LNHO and OIHP – including, notably, the gathering and analysis of epidemiological intelligence and the updating and oversight of the IHR – were incorporated into the responsibilities of the WHO.
The U.S. may thus be about to embark again on a peculiar and tangled path without the benefits of hindsight or historical perspective. In another ill-considered way, too, it seems to be embarking on a peculiar geopolitical path that is both unprecedented and precarious. If the United States goes ahead with its announced plan to withdraw form the WHO, it will leave a large vacuum in the world of global health politics that will be even larger because of the U.S.’s simultaneous withdrawal of health-related assistance programs until now funded by the United States Agency for International Development (USAID) and the President’s Emergency Plan for AIDS Relief (PEPFAR). Other countries will no doubt see a major opportunity to gain global health diplomatic advantage and turn that “soft power” into foreign policy and economic gains. Leading candidates to make aggressive strategic moves will be the countries of BRICS (Brazil, Russia, India, China, South Afric, Egypt, Ethiopia, Indonesia, Iran, and the United Arab Emirates) plus, of course, European nations like Great Britain, France, Germany, and the Scandinavian countries. The U.S. loss in good will, international presence, and strategic and economic advantage will be these other countries’ collective gain, and the United States would have to struggle mightily if it were to regain what it had lost through a major self-inflicted wound resulting from its peevish and ill-considered withdrawal from WHO.
