An ‘Americas First’ foreign policy includes global health

The Trump administration entered office promising an “Americas First” foreign policy that pays new attention on what Secretary of State Marco Rubio has called “missed opportunities and neglected partners” in the Western Hemisphere.¹ Yet, the recent disruption of U.S. global health engagement in Latin America is instead a return to an unfortunate longstanding pattern in which the United States sees the region as a source of problems rather than a partner in solving them.

On his first day in office, President Trump initiated a series of actions that unravelled twenty-five years of U.S. global health leadership. Those measures began with a renewed notice of U.S. withdrawal from the World Health Organization and a 90-day pause in new US foreign aid that evolved into a stop-work order, the effective termination of most U.S. Agency for International Development staff, and the cancellation of 5724 out of approximately 6200 US foreign assistance awards.²

The stocktaking of what the world has to lose as the United States draws down its development assistance for health (DAH) has understandably focused on Africa, the region receiving most of that aid. Yet, the loss of U.S. aid programs in Latin America and the Caribbean should give Americans equal pause, given the close proximity of those nations and the nature and importance of the essential services and institutions being disrupted.

Secretary Rubio argues that U.S. development assistance programs over time should “shrink, not expand” as the targeted health needs subside and are assumed by local governments.³ In Latin America, they have. In 1990, the region represented one out of every seven dollars that United States spent on DAH; by 2022, 2.5 percent of U.S. global health assistance went to Latin America and the Caribbean. At the same time, the mortality rate for children under 5 in the region has fallen by more than half since 2000. Most countries in Latin America and the Caribbean are middle-income, with governments and populations that paying their own bills for healthcare.⁴

While U.S. financial contribution to regional health is relatively small in absolute terms—$536 million in 2022, 0.8 percent of global DAH⁴—the United States nevertheless has had outsized influence on the health of the hemisphere in three key areas, all of which have been disrupted by recent U.S. aid cancelations and its withdrawal from WHO (Fig. 1).

Fig. 1.

US development assistance for health disbursed in Latin America in 2022 and health programs cancelled in 2025. Notes: The map reports the amount of development assistance for health from the US government received by each country relative to their own population⁴ in 2022 US dollars. The callouts highlight a small sample of the many cancelled US government health assistance programs.⁵

Support for fragile, indebted states

As Secretary Rubio acknowledges, it is the interest of the United States and every other government in the region to prevent health and humanitarian needs from overwhelming and destabilising nations.³ Haiti is in political turmoil, facing its sixth consecutive year of negative economic growth. U.S DAH to Haiti is 166 percent larger than that fragile state's domestic government health expenditure and is responsible for preventing maternal, infant and child deaths and funding more than 80 percent of the island nation's HIV/AIDS programs.⁴ The United States provides foreign assistance in the region to debt-distressed nations, such as Honduras and Nicaragua that receive, on a per-capita basis, roughly as much U.S. health aid as the Democratic Republic of Congo and Ethiopia, respectively.

Cross-border threats

The Western Hemisphere is awash with transnational threats to human and animal health, making the timing of the Trump administration's orders especially alarming. In some instances, those threats have originated from Latin America and spread northward with trade, travel, and migration. These include the record numbers of dengue fever cases reported in the Americas in 2024,⁶ nearly two dozen travel-associated Oropouche virus cases in Florida and New York,⁷ a dangerous new world screwworm outbreak menacing the livestock industry at the Mexico-U.S. border,⁸ and the fentanyl supplies that became a leading cause of death for younger American adults.⁹ In other cases, however, the public threats went the other way, with Latin American nations at grave risk from the spread of highly pathogenic avian influenza in U.S. dairy cattle and poultry farms and a measles outbreak that caused the first two U.S. deaths from the virus in a decade. From Brazil to Peru, Colombia to Jamaica, now-cancelled U.S. foreign assistance awards helped support the regional laboratories, clinics, and surveillance programs that target the cross-border health threats that countries cannot fight alone.

Regional cooperation

The U.S. has historically supported regional health cooperation in Latin America, while not always abiding by its precepts. The Pan American Health Organization was founded in 1902, before WHO, at the initiative of the U.S. government and partner nations concerned about the consequences of uncoordinated yellow fever control policies.¹⁰ The U.S. hosts the PAHO headquarters in Washington DC and provides most (54%, $78 million USD) of its assessed contributions.¹¹ The United States donated the most vaccines to the region during the COVID-19 pandemic, but those doses arrived late, months after they first became available to Americans.¹² In the meantime, the COVID-19 pandemic hit Latin America hard, with the region accounting for 14.3 percent of the world's COVID-19 deaths with just 8.1 percent of its population.¹³ To date, the U.S. has not left PAHO, but its withdrawal from WHO still hurts PAHO, which relies on Geneva for 42 percent ($295 million) of its annual budget.¹¹ U.S. example has also begun to spread. Argentina also withdrew last month from WHO, sparking fears that other populists may do the same as President Millei to curry favour with Mr. Trump.

While many of the Trump administration's executive orders are being challenged in the U.S. courts, the damage to the people receiving U.S. assistance, and to those delivering it, won't be easily undone. Once shuttered, it is hard to reconstitute migrant clinics, new drug trials, and paediatric immunisation campaigns that depend on patient routines, experienced staff, and the hard-won trust of local officials. Global public health programs are predicated on a strategy of prevention; there is no undoing the infections that occurred when an aid program fails to deliver an insecticide-treated bed net, misses a vaccine dose, or has no one available to give a pregnant mother the injection that would prevent her transmitting HIV to her unborn child.

To paraphrase the late U.S. Secretary of State George Shultz, global health security starts in your own neighbourhood. Engagement on health, including through the various regional and multilateral organisations that provide assistance to Latin America, is an indispensable part of any effort to advance the interests that America shares with the other nations of the Western Hemisphere.

Contributors

Planning: TJB and JLD; analysis: TJB, PP, and CS; drafted or revised manuscript: TJB and JLD.

Editor note

The Lancet Group takes a neutral position with respect to territorial claims in published maps and institutional affiliations.

Declaration of interests

No conflicts declared.