Global Health in the Age of Trumpism

All human endeavors -even the most noble and carefully crafted- are, at some point, destined for transformation or failure, whether total or partial. Global Health is no exception. Almost nothing we envision unfolds exactly as projected, and it falls to those of us who care about these causes to reorient them in order to keep their spirit alive; to treat them with a proper diagnosis, without allowing their enemies to let them die quietly in bed and recognizing that saving them often requires transforming them.

I once heard a Colombian poet say that he hoped his epitaph would read: “There is nothing and no one who has not disappointed me ¹”. At this stage of a professional life in Public Health, while many colleagues still seem enthusiastic about the promises and possibilities of social movements, others of us drift toward skepticism always striving to prevent it from turning into cynicism or indifference. Instead, we try to turn those doubts into a new kind of hope: to imagine other possible futures ¹; perhaps new ways of being disappointed, but which, while they last and insofar as they are honest, move the needle of change.

This is how I think about Global Health, which had already disappointed me even before it came under such open attack from nationalist movements. Many of us have long identified its contradictions and shortcomings, particularly within the mechanisms of international cooperation. Several of these are now being exploited by discourses such as Trumpism (understood here not only as a U.S. phenomenon, but as a broader expression of anti-institutional, anti-elite nationalism) to dismantle what should, in fact, be transformed.

It is clear to me that Global Health, as a perspective, an approach, and a shared purpose, remains necessary. But above all, what we need are its principles ²,³: solidarity among nations, recognition of universal basic rights, cooperation for the common good, and the deep conviction that the avoidable death of any person should matter to the entire planet.

Some criticisms of international health cooperation are not without merit. Although many valid ideas are lost amid shouting and falsehoods, there are aspects that deserve serious analysis as a starting point for a renewed Global Health. First, Trumpism advances a worldview grounded in a return to realpolitik ⁴: a logic of great powers in which we are witnessing a shift from models of indirect influence -through loans, cooperation, or political alignment- toward a more explicit and raw assertion of national interests. While such interests have always prevailed, they are now being placed more openly and aggressively above international objectives such as sustainable development or the right to health.

Within this view, there is also concern about resource use. From the United States' perspective, it is unacceptable for taxpayers to fund agendas perceived as contrary to national interests, and even when they are not, there is growing skepticism that resources are dissipating within costly, inefficient structures. On this point, they are not entirely wrong: inefficiency is real and persistent.

A significant -and systematically underestimated- portion of cooperation resources does not reach people, as has been documented ⁵. Some of the investment is lost to cost overruns, disproportionate fees charged by universities and consultants, per diems, reports that circulate more than they transform, and interventions that address short-term contingencies without building lasting capacity. The problem is not only how much is invested, but how: too often, cooperation ends up financing the maintenance of its own machinery before generating a sustained health impact. This is perhaps the system’s most uncomfortable blind spot.

However, this critique does not justify a stance of persecution against international cooperation. It has been fundamental in addressing numerous global health challenges that would otherwise remain neglected ⁶. There are highly relevant initiatives such as the President’s Emergency Plan for AIDS Relief (PEPFAR), launched in 2003 under the administration of George W. Bush, which has been key in expanding access to antiretroviral treatment, prevention, and the strengthening of health systems in many low- and middle-income countries, with well-documented impact ⁷.

And although in this and some other cases (thanks, among others, to the mediation of the World Health Organization) resources have been preserved after demonstrating their impact on human lives, this is not generally the case. In many other programs -especially in African countries with high dependence on cooperation- substantial increases in inequities have been projected in the face of potential funding cuts. In fact, recent models estimate that reductions in U.S. international aid could lead to more than 14 million additional deaths by 2030, including millions of children, as well as significant increases in mortality from HIV, malaria, and other preventable diseases ^8-10.

A second element is the reaffirmation of the primacy of U.S. interests over those of other powers, amid growing geopolitical tensions with countries such as China or Russia, and even with traditional allies. This narrative has been effective in advancing the idea that multilateral organizations such as the WHO respond to external or ideological interests, when in many cases what they reflect are disagreements with agendas that challenge certain conservative frameworks. Against this backdrop, the aspiration for a truly multipolar world appears increasingly distant. Yet the risk is clear: that low- and middle-income countries become subordinated to the logic of a single dominant power. This is not new - it never has been - but it could become worse than it has ever been.

A third and final element of Trumpism, shared with other nationalist movements, is the construction of a narrative of a “people” opposed to establishment elites. Within this logic, leaders of international cooperation are portrayed as elitist bureaucrats who exploit resources to perpetuate their own interests, indifferent -or even opposed- to the needs of ordinary people.

This caricature, though unfair as a generalization, is not entirely baseless: there is a liberal elite increasingly distant from people; a system that tends to perpetuate itself through constant funding; a lack of self-criticism; and a progressive detachment from reality within many agencies and actors.

It is also true that there are deep inconsistencies. In the name of solidarity and high human values, some find in cooperation a way of life, yet reproduce in their daily environments -within their teams, families, or circles- logics of exclusion, racism, and classism. In practice, they replicate precisely what they claim to oppose. Perhaps there are discourses, programs, and individuals that have grown too comfortable, accustomed to a model of cooperation that is insufficiently questioned. And although deeply misguided in many of its premises, movements such as Trumpism have forced an uncomfortable reckoning that compels us to rethink the system. That reorganization was necessary, but it is not being done as it should.

It is particularly concerning that, in order to preserve status, funding, or prestige, some researchers accept the censorship or silencing of fundamental categories such as social justice or the visibility of historically excluded populations.

Paradoxically, what little can be salvaged from Trumpism for Global Health stems precisely from what makes it so problematic: the discomfort it generates. That discomfort should push us to ask what kind of Global Health is possible in this world, what kind is necessary, and to recognize that it cannot be the same as the one we once knew.

We need a Global Health that is less dependent on one or a few countries; more sustainable, more honest, and truly multipolar; capable of building consensus without losing its principles.

We had a dream that partially failed. We cannot abandon it.

We need a better dream.