Intended for healthcare professionals


Global health under fire: Trump and covid are just two of the threats

BMJ 2020; 369 doi: (Published 08 June 2020) Cite this as: BMJ 2020;369:m2213

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  1. Mara Kardas-Nelson, freelance journalist
  1. Berkeley, California, USA
  1. marajenn{at}

When Donald Trump cut US funding to WHO, it was just one of many power plays in global health affecting pandemic and other international health efforts. Mara Kardas-Nelson describes the effects on many lives

On 29 May 2020 President Donald Trump announced a halt to US funding for the World Health Organization, claiming that the body had mismanaged its efforts to stop the spread of the new coronavirus.1 The announcement came after a series of threats over the past few months.2

WHO regularly has to chase American funding. The US has not paid its mandatory dues for 2020,3 nor has it paid most of 2019’s bill; at last count it owed nearly $200m (£160m; €180m). It is not alone, however: others in arrears include major funders such as China, which like the US owes WHO 20% of its mandatory funding.

WHO’s director general, Tedros Adhanom Ghebreyesus, responded to Trump’s announcement only by thanking the US for its historical support, adding, “It is WHO’s wish for this collaboration to continue.” As WHO’s largest funder, there’s no question that a change in US contributions could irrevocably harm the organisation. But in the short term WHO is on track to receive the funding it has solicited specifically for its covid-19 response, receiving support from countries such as Kuwait and Japan, and the European Commission.3

In an interview with The BMJ before Trump’s most recent announcement, Amanda Glassman, executive vice president at the Center for Global Development in Washington, DC, said she didn’t think a change in US funding would immediately affect WHO’s coronavirus efforts. “But it could have devastating long term impacts,” she said.

Internationally, fundraising efforts for other large pandemic response efforts aren’t going well. As at the end of April, the most recent data from the Global Humanitarian Response Plan, a UN appeal—the largest funding appeal in the organisation’s history—showed that it was only half funded.45 The money is intended to provide health, economic, and other support to 117 million people through UN and affiliated bodies, including WHO.

In a report published on 1 May Glassman and several colleagues noted that such appeals were likely to be the tip of the iceberg, with “trillions, not billions . . . needed to support countries as they struggle to mount an effective response amid the growing economic fallout.”6

Everybody hurts

Only 5% of funding asked for in the global response plan would go to small non-governmental organisations. And one of the world’s largest NGOs, Oxfam, has already announced that it is ending operations in 18 countries owing to lack of funds. According to the independent news agency the New Humanitarian, the closure will affect 1450 staff and 700 partner organisations.7

Although the White House said that the millions of dollars that would have gone to WHO would be given to “others directly engaged in the fight,”8 Glassman says she’s seen no evidence that this shift has happened. The US has already given nearly a billion dollars to covid related efforts in 120 countries, says its international development agency, USAID, but there’s little information from most donors on which organisations are getting funds or for what purpose. The Center for Global Development, a non-profit think tank based in Washington, DC, points out that it’s not entirely clear where most covid funds are going or how they’re being used, whether the support is from USAID or the UK Department for International Development, and that this has happened before, with a lack of transparency plaguing aid efforts after the Haiti earthquake in 2010 and the 2014-16 outbreak of Ebola virus disease in West Africa.6

Donors are also looking after their own interests. Around $23m of USAID funds has been earmarked to provide US-made ventilators to recipient countries,9 such as the 1000 sent to South Africa in May.10 And National Public Radio reported that although the US had shipped personal protective equipment (PPE) to affected countries such as China in February, that channel was later blocked, with the secretary of state, Michael Pompeo, saying in April that the US would not donate PPE from the country, citing concerns about domestic shortages.11 (The country is not alone here: 70 countries have restricted, to varying degrees, exports of medical supplies.12)

At the time of writing, USAID recipients can’t use funding to buy PPE without prior approval. When The BMJ asked for clarification, a USAID spokesperson responded: “While the interagency process on PPE procurement continues, we continue to remain sensitive to the needs of humanitarian beneficiaries around the world while balancing the urgency of the domestic requirements here in the United States.” USAID guidance states that recipients cannot shift to covid related activities unless they receive written authorisation to do so.13

Not spreading the wealth

In a commentary published in the Lancet in early May global health researchers warned that “even when there is enough money, many African health authorities are unable to obtain the supplies needed as geopolitically powerful countries mobilise economic, political, and strategic power to procure stocks for their populations.”14

The authors pointed out that though billions had been pledged by organisations such as the Bill and Melinda Gates Foundation and the Wellcome Trust to accelerate vaccine development, there was no explicit commitment to ensuring that new technologies would be equitably distributed internationally. “We have seen this before,” they wrote. “In the AIDS pandemic lifesaving diagnostics and drugs came to many African countries long after they were available in Europe and North America.”

As a result, some countries are scaling up their own internal response.14 South Africa, Kenya, Zimbabwe, and Morocco are trying to increase local production of PPE, and Senegal’s Institut Pasteur is working on a rapid test that could be produced in the millions and cost just a few dollars a test. The country has been a leader in the coronavirus response, with efforts beginning in January.15 Thus far, it’s only seen a handful of deaths.

Meanwhile, the UN estimates that tens of millions of covid-19 tests will be needed in Africa, but health officials say they’re already struggling to obtain them because they’ve been purchased for use in North America and Europe.14 The New Humanitarian points out that while some countries, such as Uganda, have tested tens of thousands of people, neighbouring Tanzania has only conducted 652 tests; 509 have been positive.16

Even South Africa and Ghana, which together account for half of the tests conducted on the continent, are facing an extreme shortage of tests. John Nkengasong, the head of the Africa Centres for Disease Control and Prevention, wrote in a commentary for Nature that “the collapse of global cooperation and a failure of international solidarity have shoved Africa out of the diagnostics market,” as “African countries have funds to pay for reagents but cannot buy them.” 17

And budgets may be getting tighter as a global recession looms, affecting everything from health programmes to larger social support. Glassman notes that “in high income countries the policy is ‘we’ll spend what it takes’ and in low and middle income countries it’s ‘we’ll spend what we can.’”

The World Bank also predicts that remittances—which make up more funding to low and middle income countries than foreign direct investment—will fall by 20% in the coming months.18 While the World Bank and International Monetary Fund have announced covid related funding, some of that money is being diverted from other programmes, and some is being offered as loans, with conditions countries may not be able to meet. The former UK prime minister Gordon Brown recently excoriated the G20 wealthiest nations for not coming up with a global economic plan. “This is not just an abdication of responsibility,” he wrote in the Guardian recently.19 “It is, potentially, a death sentence for the world’s poorest people, whose healthcare requires international aid and who the richest countries depend on to prevent a second wave of the disease hitting our shores.”

Cracks exposed

While the world focuses on covid-19, other health issues are falling by the wayside. Even in the US the pandemic has affected vaccination programmes.20 There’s already a looming reproductive health crisis in Africa as clinics have closed down or reduced hours thanks to lockdown orders, with women unable to access services as they’re told to stay at home.21 Production of contraceptive supplies, mostly made in India and China, has also been slowed as factories have shut down for months. Marie Stopes Kenya, a major family planning provider, estimates that it may be unable to avert 100 000 unintended pregnancies, 65 000 unsafe abortions, and 500 maternal deaths under the worst case scenario.21

Poor countries across Latin America and Africa are bracing for a coronavirus surge that could overwhelm fragile health systems. The authors of the aforementioned Lancet commentary note that Malawi has 0.1 critical care beds per 100 000 people and that “most counties in Kenya reportedly have no functioning ventilators.”14 Ecuador, one of the hardest hit Latin American countries, has 1.6 hospital beds for every 1000 people, whereas Germany has 8.2 per 1000, World Bank data show. Even relatively wealthy South Africa has about 7000 critical care beds for 60 million people.22

“We had this idea that this [covid-19] would be a game changer on health systems, but I don’t see a huge amount of emphasis on spending for overall healthcare,” says Glassman. “The response should be: let’s invest in better triage and management, [and] sustain primary healthcare during this time. In our own country, incredibly, our president has spoken about rolling back insurance for those who can’t pay the full premiums. It’s incomprehensible.”

As for who should lead the call for health system strengthening, Glassman looks not to the US but to WHO. “There needs to be a stronger message, and WHO has an important role to play in that.” She wonders, though, whether the body is quiet because it is under financial and verbal attack. “It’s pretty hard to make a strong statement when there’s this ongoing discussion about your core capacities and functions,” she says.


  • Competing interests: I have read and understood BMJ’s policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer view: Commissioned; not externally peer reviewed.


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