Is there any point in writing about this farce of a strategy? Not really. I mean, for me sure because it’s cathartic. Writing blogposts is far less painful than punching a wall or myself in the face – less amusing to watch, though. Maybe I should video myself doing that instead and post it on Youtube for content creators to ‘react’ to? “Oh look, he’s got to the bit where Rubio boasts about how American leadership in global health has helped keep Americans safe while apparently forgetting that one and a half million Americans have been killed by Trump’s asinine response to Covid-19. Will Dr Harmer punch the wall again? No, he’s gouging his eyes out with that spoon”. Honestly, you’d be better off reading Ngozi Erondu’s excellent analysis, or the writing by Crawford and Barry or Godbole and Kenny, than read my half-baked analysis. But if you decide to stick around, great! The America First Global Health Strategy (AFGHS) Executive Summary opens with this arrogant assertion: “The United States is the world’s global health leader”. It’s not of course, the World Health Organisation is. But even if the World Health Organisation had never existed, I think there are at least four broad reasons why the United States is not the world’s global health leader.
The first reason why the United States is not the world’s global health leader is because its President and health leadership team are, how can I put it, unfit for purpose. There’s no point analysing a strategy paper if you’re going to ignore the fundamental point that its architects either don’t understand or ignore or (worse) deliberately seek to undermine basic health science. Have you forgotten all the incomprehensible things that Trump said during Covid or the dumb things he continues to say in the present? Pre-pandemic, he was struggling with his internal organs, claiming (lung-in-cheek no doubt) that “kidneys had a special place in the heart”. Watching the video, it’s not entirely clear that he’s making a joke. A year later as the pandemic took hold, Trump was instructing his health experts to “look into” whether “heat or light” or – he mused – disinfectant could be effective treatment for the novel coronavirus. He was definitely not joking this time and, following his idiotic comments, poison centres reported an increase in calls from people who had ingested cleaning products such as Lysol. And when the US Centres for Disease Control advised wearing face masks – a non-pharmaceutical intervention that consistently ranks highest in lists of most effective preventive responses – Trump publicly and pointedly observed that the CDC advice was voluntary and that he was “choosing not to do it”. Cut to the now, and Trump continues to spew dangerous and completely unsubstantiated health advice. In September 2025, for example, he publicly advised pregnant women to limit their consumption of paracetamol, asserting with no evidence whatsoever that “it’s not good”.
Human Shar Pei Robert Kennedy is the US secretary of health and human services. Judging by his Wikipedia page, Trump might as well have appointed Pennywise to the role. It’s beyond comprehension that someone with a track record of vaccine denialism as extensive as his could worm his way into that job. For good reason, seventy seven Nobel laureates wrote to the US Senate imploring it not to approve Kennedy’s appointment as it would “put the public’s health in jeopardy”. Kennedy either does not know what he is talking about, in which case he shouldn’t be in the job, or he is deliberately deceiving everyone in order to pursue an alternate agenda, in which case he shouldn’t be in the job. You can see him at work in this 2024 Fox News interview where he first clarifies that he does believe that autism comes from vaccines (it doesn’t) but then shifts the focus of the interviewer’s question to a more general and technical-sounding issue around vaccines being exempt from pre-licensing placebo-controlled trials (they aren’t – both Pfizer-BioNTech and Moderna’s vaccines were subject to randomised, double-blind, placebo-controlled phase 3 trials). Kennedy’s aim is to sow doubt in the mind of the general public that there is something ‘fishy’ about vaccines and that they are somehow exempt from normal scientific processes (they aren’t). The opposite is true but he knows that if he starts bandying around phrases like ‘pre-licensing placebo-controlled trials’ then journalists like Jesse Watters won’t have the knowledge or confidence to call him out. No government can claim to be the world’s global health leader when it demonstrates this level of stupidity and mendacity.
The second reason why the United States is not the world’s global health leader is because it is so bad at protecting the health of its own population at home. It’s perhaps not surprising that Covid is mentioned just once in AFGHS. But think about that for a second – this strategy document refers to a pandemic that resulted in up to 20 million deaths world-wide only once in its 40 pages and then as a single word in a list of four epidemics and pandemics – second behind Ebola. It’s as if it never happened. Presumably, that’s because Trump spectacularly and tragically failed to protect the health of the US population – 130 million infections and 1.23 million deaths since 2020 – and he and his minions don’t want to be reminded of that egregious dereliction of duty. No State can claim global health leadership when its national policies result in that many deaths from a health threat that other States responded to much more effectively.
Furthermore, no State can claim global health leadership when its own health system is dysfunctional. The US health system works for the wealthy but not for the poor. This is just stating the obvious of course – see Glaser in 1993, Brown in 2002, the American College of Physicians in 2008, Papanicolas in 2018, etc. etc. In 2024, International Citizens Insurance reviewed multiple studies in an attempt to rank countries’ healthcare provision. In some studies – the Mirror, Mirror study, for example – the US comes last every year since 2006, but across all the studies it comes 69th out of 103 countries. Singapore is first, followed closely by Japan, South Korea, Taiwan and China. Crawford and Barry summarise US performance thus:
The U.S. health system consistently underperforms compared to other high-income nations, leaving Americans with the highest per-capita spending ($13,432 per person) but the lowest life expectancy (78.4 years) and the highest maternal mortality ratio (22 maternal deaths per 100,000 live births in 2022).
The lack of self-reflection in AFGHS is just plain weird. The writers of it know what a disaster Trump’s response to Covid-19 was and they are attempting to expunge that event from the policy record. Given the extreme mortality and morbidity in the US from Covid-19, you would expect that country’s Executive to regard the post-pandemic period as a moment for humility and lesson-learning. Not so. Instead, Rubio has produced a farcical, reality-defying strategy and – bizarrely – thinks that ‘the world’ is going to run with it. Again, just pause for a second and ask yourself why on earth ANY country would want to emulate a health system as bad as the US system?
The third reason why the United States is not the world’s global health leader is because of its foreign policy, which has historically and into the present directly and indirectly killed thousands and thousands of people. It’s a mystery to me why this side of the global health ‘ledger’ is missing from pretty much every ‘what has the US done for global health’ type analysis. To be clear, the US has for a long time – perhaps always – been a rogue state. Throughout the 20th Century, its intelligence agencies murdered their way across South-East Asia and Latin America, destabilising governments, giving the ‘green light’ to dictators to slaughter their people, executing regime changes whenever it felt like it, and generally wreaking havoc everywhere they went. The result: lots and lots of innocent people were killed, often horribly. I remember reading about former Indonesian President Suharto’s treatment of captured East Timorese resistance fighters. You’ll recall that the US knew Suharto was going to invade East Timor and did nothing to stop it. One favoured method to permanently dispatch prisoners was to drag them across stretches of barbed wire until all their skin flayed off.
But all of that is in the past and this century US foreign policy is a ‘new man’. It’s turned over a new leaf, made a fresh start, and walks tall in the knowledge that it does good, for the world, all the time. Yes, the US did invade Afghanistan in 2001 and occupied the country until 2021 when it abruptly left and handed back control to the Taliban – the force it initially set out to defeat. Fortunately, only about 176,000 to 212,000 people were killed in that little exercise. And, ok, there was that thing in Iraq in 2003 when the US attacked the country resulting in up to 100,000 excess deaths between 2003-2004, and approximately 655,000 total deaths by 2006. Yes, it is the case that the US was able to develop its global networks throughout these military incursions, notably its network of torture ‘black sites’ – where illegally abducted detainees enjoyed the full range of CIA enhanced interrogation techniques. And, true, there have been all those US drone strikes in Yemen, Pakistan, Somalia, Libya, Afghanistan, Iraq, or Syria over the past couple of decades – strikes that have likely killed tens of thousands of people. But, BUT, we have to forgive, forget, and move on, right? Look, it’s 2025 now, Andrew, and the US doesn’t do that kind of regime change anymore. Ok?
The fourth reason why the United States is not the world’s global health leader is because – aided and abetted by its government – the actions of many US multinational corporations are inimical to global health. For example, US corporations have done the following: advertised, marketed and produced processed food that has killed thousands of people, harmed millions more and contributed to a global obesity epidemic; they advertised, marketed, manufactured and sold $318 billion of arms and military services in 2023 – ordnance that is used primarily to kill and maim people; and they have led the world in undermining efforts to curb greenhouse gasses, with the US FFI in 2024 producing 38 trillion cubic feet of dry natural gas, 13.2 million barrels of crude oil per day, and 512 million short tons of coal.
Obesity within the US is a health emergency, particularly for its children, killing 300,000 Americans each year. By mid-century, some estimate that 100% of the US population will be obese. Soda consumption is a significant contributor, with Coca Cola spending $$ billions each year promoting its beverages globally – primarily (if indirectly) to children. When US arms companies aren’t flooding the global market with guns, they’re dealing them at home – aided and abetted by US media corporations that seamlessly weave gun ownership into popular culture, manufacturing perfectly the need to consume their products. While shootings in schools remains for many Americans a price society must pay for the ‘right’ to bear arms (so far, there have been 44 child murders from gunfire in US schools in 2025), it is perceived by the rest of the world as a jarring, brutal dystopia. US lobbying corporations are rightly referred to as ‘merchants of doubt’ and work to undermine political and legal efforts to limit regulation that might harm its clients’ profits. While the world watches as Jamaica’s health infrastructure struggles with the impact of Hurricane Melissa, US energy lobbying companies will be attending COP30 over the next two weeks with the shared aim of impeding progress by Conference delegates to limit the use of fossil fuels. Influence Map has a searchable database where you can get a sense of US lobbying influence at COP 30.
The United States is NOT the world’s global health leader. Only deluded grifters occupying the Whitehouse think that. I have deliberately not repeated the obvious criticisms of AFGHS in this post. Others have, rightly, pointed out all of its embarrassing weaknesses: the narrow focus, the inequity, the economic costing and political realities that would make the strategy unfeasible, its lack of appeal, the clumsy attempts to frame the strategy as a move away from dependence when in fact it is the complete opposite of that, the pathetic appropriation of decolonisation movement arguments in an effort to get progressives on board, the tragic pretence that the Covid pandemic never happened, and the writing out of all the work that WHO does that the strategy would seek to replicate. It’s so stupid that this strategy exists. In some respects, it’s an insult to my profession as an academic – a profession predicated on the assumption that politicians have at least some integrity and some intelligence, and aren’t so craven and driven by self interest that they are willing to subvert the foundations of knowledge and science for political gain – to see this kind of work being published. But in other respects, it validates our work because we have the knowledge and skills to critique it, and encourage others to resist it. This strategy document has nothing to do with global health and everything to do with the self-interests of one State, the United States. That’s not what global health is, and it’s not what global health should be.
I’m going to end with a general observation. States can’t be global health leaders because they are violent institutions that kill people. They’ve been doing that day in, day out since 1648 and the Peace of Westphalia. Yes, a State can give money to good causes – it looks good and it keeps its population happy. Some politicians like it because of the optics, and it’s what some ideologies have to do to stay in the club – you can’t be a liberal democracy if you don’t at least support multilateral organisations like the WHO. But at the same time, those States undermine global health so profoundly through their actions that you wonder why we have States at all. The only way States can moderate and mitigate their violent actions is through International Organisations, where (for example) they confer leadership on global health matters to the United Nations system. The United States is the worst of all States because it is the most powerful and has the biggest of everything, and has used that advantage to do more damage to global health than all the other States combined. And now it wants to completely bypass the existing multilateral order and recreate a new bilateral order in its own image. Unfortunately, that currently seems to be a white, wealthy, male, fundamentalist Christian, racist, violent, and ignorant ass hole.
I’ll pass, thanks.
Andrew
Talking of Suharto, I see that Indonesian President Subianto awarded him the title of ‘national hero’ over the weekend! At least it wasn’t the Nobel Peace Prize (which Kissinger received in 1973).
And there has been some reporting – also over the weekend – that US PEPFAR aid will in the future require recipient countries to sign a 25 year MOU that includes a “specimen sharing agreement” whereby countries would share – within five days of detection – samples of any pathogens with epidemic potential (see Cullinam, Lay, and Rigby, for example). This should not come as a surprise though to anyone who has read the AFGHS. Here’s what the strategy has to say: “The U.S. government will use a combination of U.S.-funded disease surveillance capabilities, technical collaborations, and diplomacy to obtain real-time information about an outbreak’s trajectory and any mutations to the pathogen causing disease. We will engage counterparts in the local government to understand the risks for additional spread and obtain basic genetic sequencing information or physical samples of the pathogen to inform the response and development or deployment of medical countermeasures”. What we are learning from the recent news is how the “basic genetic sequencing information or physical samples of the pathogen” will be obtained. Readers of the AFGHS will have realised when the strategy was published in September that this would compromise ongoing PABS negotiations, just as it will potentially compromise much of the other already existing global health surveillance work, such as that conducted through GOARN. AFGHS is telling the world that the US wants to and intends to replace multilateral global health systems with its own bilateral ones – pathogen sharing, surveillance, FDA-approved products instead of WHO’s EML, etc.
I was invited to participate in a panel discussion on this topic at Chatham House on Thursday. You can watch the recording here: https://www.chathamhouse.org/events/all/open-event/shaping-future-global-health-who-will-make-rules