Intended for healthcare professionals


US decision to pull out of World Health Organization

BMJ 2020; 370 doi: (Published 24 July 2020) Cite this as: BMJ 2020;370:m2943

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Linked Opinion

What Trump’s threat to defund the WHO means for the United States and the world

  1. Devi Sridhar, chair of global public health,
  2. Lois King, PhD candidate
  1. Global Health Governance Programme, University of Edinburgh, Edinburgh, UK
  1. Correspondence to: devi.sridhar{at}

Loss of funding could be devastating for critical global health agendas

President Donald Trump’s announcement on 29 May 20201 that the US would withdraw from the World Health Organization came as little surprise to those who had been following his administration’s attempts to find a scapegoat for the covid-19 crisis. The attacks on WHO have to be seen within a larger geopolitical context of increasing tension and blame between the US and China, with WHO caught in the middle like a child not wanting to pick sides between warring parents.2 But are these attacks fair, and what will US withdrawal mean for WHO?

WHO’s role

WHO was established in 1948 as the chief director and coordinator of international health work in the United Nations. Its roots are deeply embedded in outbreak response—the initial rationale for sovereign states coming together was to agree on infectious disease regulations at the first international sanitary conference in 1851.3

WHO’s strengths are in its technical, normative, and convening efforts. Technically, it shares data between countries including standards, guidelines, and key health information. Normatively, it has the unique ability to agree international law, such as the International Health Regulations, which govern the reporting and response to health outbreaks, as well as set norms through codes of practice and global strategies. WHO’s convening efforts centre on its World Health Assembly, which brings together governments from across the world to agree on priorities, debate issues such as access to essential medicines, and pass resolutions for action.4 Although WHO can advise, support, and encourage, it cannot go into countries to change policies, investigate the source of outbreaks, or penalise bad behaviour.

Covid-19 response

WHO has attempted to bring these three roles together to tackle the covid-19 pandemic. After China reported the new outbreak to WHO’s country office on 31 December 2019, WHO quickly sent out a bulletin to other countries about a new respiratory pathogen.5 As more data emerged, the organisation helped to develop test kits that could be sent to parts of the world lacking laboratory capacity and tried to encourage data sharing from China so that other countries could learn.6 On 30 January 2020 WHO declared covid-19 a public health emergency of international concern, a strong warning that the virus was on its way and countries should prepare.7

On 24 February it’s mission to China reported on the epidemiology of the virus and China’s response. The clear messages were to prioritise testing, contact tracing, isolation of carriers and their contacts, physical distancing as needed (lockdowns), protection of health workers through adequate protective equipment, and ramping up hospital capacity.8

WHO was criticised at the time for praising China’s handling of the epidemic—now understood to be the price for China’s ongoing cooperation.9 Since then, WHO has continued to update its technical advice and has monitored all parts of the world when donor countries in Europe and the US were consumed with their own outbreaks.

WHO’s job is technical advice, producing international guidance, and bringing countries together. The recent virtual World Health Assembly showed that the organisation has delivered those roles adequately.10

Loss of funding

In the medium term the US withdrawal from WHO will cause serious financial damage. The US is one of the largest contributors of “extra budgetary funds,” which make up 80% of WHO’s total budget.11 Although influential organisations such as the Bill and Melinda Gates Foundation and the European Commission are important donors in global health, the potential funding gap left by a US withdrawal will be hard to fill. Altogether, the US granted an estimated $419m (£330m; €360m) to WHO in 2018-19, roughly 16% of WHO’s total funding for these two years.12 This magnitude of deficit could be devastating to critical global health agendas such as child survival, polio eradication, and neglected tropical diseases, which aren’t covered by other organisations.

However, the legal ramifications of such a withdrawal mean that the Trump administration may require Congressional approval. In 1948, a joint resolution by the Senate and the House of Representatives requires the US to give at least one year’s notice and to meet all outstanding financial obligations to WHO in the financial year leading to an exit.13,14 Currently, $60m is outstanding from the latest fiscal year, not including debts of nearly $40m from previous years.15 These are the checks and balances within the US political system that prevent rash actions by any one player. If Joe Biden wins the November presidential election, he has already promised to reverse Trump’s decision to withdraw.

In the larger trajectory of history, Trump’s words will likely remain just words especially if Joe Biden wins the November election.There is even time for a U turn from Trump. But WHO should hope for the best while preparing for the worst—through an emergency response from donors and increased contributions from remaining member states.16 Whatever happens, the organisation’s work must continue. No other agency is able to perform all three important functions.


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

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


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