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America First, Global Health Last

  • public-health
  • global-health
  • healthcare-policy
  • data-analysis

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 aid[1], including the President's Emergency Plan for AIDS Relief (PEPFAR). For context: PEPFAR is credited with saving 26 million lives since 2003[2]. 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 treatment[3]. On January 24, those people were cut off.

What Happened Next

Within days, documented impacts emerged:

  • Clinics across Africa, Asia, and Latin America closed[4]
  • Antiretroviral medication stockouts began[5]
  • Healthcare workers were laid off mid-shift[6]
  • 220,000 patients who visit PEPFAR-supported clinics daily were turned away[7]

In Mozambique, HIV testing dropped from approximately 30,000 tests per month to near zero immediately after the funding freeze[8]. In Johannesburg's APACE program, the number of people tested for HIV fell by 75% within weeks[9].

People began rationing their HIV medications—taking pills every other day instead of daily[10]. This creates drug-resistant HIV strains[11].

The Human Cost (Documented)

A limited waiver was issued February 1 to exempt "life-saving" services[12], but implementation has been incomplete. As of September 2025, UNAIDS reports:

  • 40% of 70 UNAIDS country offices witnessed end to community-led services[13]
  • 30% reported international NGO services stopped[14]
  • Medication stockouts in multiple countries[15]
  • Staffing cuts at HIV/AIDS clinics[16]
  • "Rising levels of stigma, discrimination and mortality rates"[17]

USAID—which administered 60% of PEPFAR's bilateral funding[18]—was permanently dismantled in early 2025. Most USAID employees were placed on leave or dismissed[19]. Without USAID staff, even programs with waivers couldn't restart due to lack of administrative capacity[20].

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 2030[21]
  • 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 2030[22]
  • 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 2030[23]
  • Depends on success of mitigation efforts
  • Drug-resistant strains already emerging[24]

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 2025[25].

The Money

PEPFAR's FY2024 budget: $6.5 billion[26] Current administration's FY2026 proposal: **$4.6 billion** ($1.9 billion cut)[27]

For comparison:

  • $1.9 billion = 95 elementary schools[28]
  • $1.9 billion = food for 847,000 Americans for one year[29]
  • $1.9 billion = 0.03% of the $6.75 trillion federal budget[30]

Historical Comparison

2003-2009 (Previous Republican Administration):

  • Created PEPFAR with $15 billion initial commitment[31]
  • Saved an estimated 1.1 million lives in first 5 years[32]
  • Built bilateral relationships through health diplomacy
  • Established U.S. as global leader in HIV/AIDS response

2009-2017 (Previous Democratic Administration):

  • Maintained and expanded PEPFAR[33]
  • Budget grew from $5.6 billion to $6.8 billion[34]
  • Supported 11.5 million people on antiretroviral therapy by 2016[35]
  • Zero disruptions to medication supply chains

2021-2025 (Previous Democratic Administration):

  • Maintained PEPFAR at $4.7-4.85 billion[36]
  • Supported 20.5 million people on treatment[37]
  • Zero disruptions to medication supply
  • Strengthened pandemic preparedness infrastructure

2025-Present (Current Administration):

  • Froze all PEPFAR funding January 24[38]
  • Dismantled USAID permanently[39]
  • Proposed $1.9 billion cut[40]
  • Documented clinic closures and medication stockouts within 72 hours[41]
  • 83% of USAID global contracts canceled[42]

The WHO Withdrawal

On the administration's first day, an executive order was signed withdrawing from the World Health Organization[43]. 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 annually**[44].

That's the cost of 50 elementary schools.

WHO coordinates:

  • Global influenza surveillance (critical for annual vaccine development)[45]
  • Disease outbreak response[46]
  • International health regulations[47]
  • Pandemic preparedness[48]
  • Climate and health programs[49]

The CDC was ordered to immediately cease all collaboration with WHO[50]. 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 network[51]
  • U.S. lost access to real-time international disease surveillance[52]
  • Global flu tracking systems now operate without U.S. input[53]
  • Dengue outbreaks in Americas reached 12.6 million cases (triple previous year) with reduced U.S. coordination[54]

For context: Approximately 30,000 elderly Americans die from flu complications annually[55]. 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 hampered[57].

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 million[58] 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 Africa[60]
  • CDC sent 1,400 responders[61]
  • Spent $5.4 billion on emergency response[62]
  • Zero U.S. deaths from Ebola transmission
  • Contained outbreak before global pandemic

2003 HIV/AIDS Response (Previous Republican Administration):

  • Created PEPFAR with bipartisan support[63]
  • Made U.S. the global leader in HIV/AIDS response
  • Estimated 1.1 million lives saved in first 5 years[64]
  • Built lasting diplomatic relationships through health cooperation

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

  • Maintained WHO partnership[65]
  • Sustained PEPFAR funding[66]
  • Provided COVID-19 vaccines to 115 countries[67]
  • Strengthened global health security frameworks

2025 Response (Current Administration):

  • Withdrew from WHO on day one[68]
  • Froze PEPFAR funding on day four[69]
  • Dismantled USAID[70]
  • Cut $3.2 billion from global health[71]
  • Documented clinic closures and medication stockouts within 72 hours[72]

The Trust Deficit

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

  • Clinics scrambled to inform patients[73]
  • Healthcare workers lost jobs without notice[74]
  • Partner countries questioned U.S. commitment[75]
  • Ongoing research projects were abandoned mid-study[76]

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 HIV[79], received $462 million from PEPFAR in FY2023[80]—the largest recipient globally. The country already pays for 83% of its HIV/AIDS efforts[81], and PEPFAR was supporting a planned 5-year transition to full domestic funding[82].

Research published in Annals of Internal Medicine projected that if PEPFAR funding is not replaced, South Africa could experience[83]:

  • 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 counseling[85]
  • Prevention programs (including PrEP)[86]
  • Mother-to-child transmission prevention[87]
  • Laboratory infrastructure[88]
  • Health information systems[89]
  • Healthcare worker training[90]
  • Supply chain logistics[91]

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 months[94].

Previous Republican and Democratic administrations understood this. PEPFAR was created explicitly as a national security investment[95]. The 2014 Ebola response deployed thousands to West Africa to prevent the disease reaching America[96].

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 role[97].

The current administration dismantled these protections for the cost of 160 elementary schools—in a nation with 130,000 K-12 schools[98].

Congressional Response

Congress has pushed back on some cuts. In July 2025, Congress voted down a proposed additional $400 million rescission from PEPFAR[99]. However, the broader funding freeze and USAID dissolution have proceeded.

Twenty-five states and the District of Columbia sued the federal government over PEPFAR delays[100]. Two federal judges ruled in October 2025 that the administration had to continue payments, but the federal government appealed[101].

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 2030[102]
  • Emergence of drug-resistant HIV strains[103]
  • Weakened pandemic preparedness[104]
  • Loss of U.S. diplomatic influence[105]
  • Damaged relationships with partner countries[106]
  • Potential for diseases to reach U.S. borders[107]

The economic cost of the COVID-19 pandemic in the U.S. alone was approximately $15 trillion[108]. 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 response[109].

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 inevitable[110]—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 lives[111].

The question is whether we learned it.

References

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  2. KFF, October 16, 2025. ↩︎

  3. Science, "'A bloodbath': HIV field is reeling after billions in U.S. funding are axed." https://www.science.org/content/article/bloodbath-hiv-field-reeling-after-billions-u-s-funding-axed ↩︎

  4. NPR, "Trump's 'stop-work' order for PEPFAR cuts off anti-HIV drugs for patients," January 28, 2025. https://www.npr.org/sections/goats-and-soda/2025/01/28/g-s1-45030/pepfar-trump-drugs-stop-work ↩︎

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  64. KFF, Historical PEPFAR data. ↩︎

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  66. KFF, October 16, 2025. ↩︎

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  111. Harvard T.H. Chan, January 23, 2025. ↩︎