US aid cuts are an opportunity to reimagine global health

US foreign policy has always been linked to the idea of US superiority and self-interest. US aid is no different and has promoted a culture of white saviorism, dependence by the global south and paternalism — rather than partnership and allyship¹.

Executive orders by US President Trump to withdraw from the World Health Organization and halt most foreign development assistance has sent major global shockwaves and undermined recent gains achieved in global health, but should be seen in the context of a rise in authoritarianism worldwide and the erosion of international cooperation.

Cuts to tuberculosis and HIV treatment programs are among the most worrying for the African region. South Africa is one of the biggest recipients of PEPFAR aid, receiving US $332.6 million in 2024. In the past few days, many HIV clinics across South Africa told their shocked clients that they had to discontinue services. The disruption of drugs will undoubtably cost lives.

As the USA fails in allyship, other global north governments may do the same. In a more equitable world, no single country would have so much influence on the health of so many outside its borders. As bad as the crisis is, it presents an opportunity to reconceptualize global health and not only to reduce the reliance of the global south on the global north but also to consider an intentional approach to dismantling the skewed financial, epistemic and power dynamics of global health².

First, governments in the global south should invest in their own healthcare and in their own health science – reinforcing science education, research training and research infrastructures that enable innovation to thrive and to build a knowledge economy.

Second, scientists in the global south need more south–south networks for solidarity and learning across settings. For example, BRICS countries are increasingly collaborating on science and expanding to include more countries.

Third, funding decisions must be informed by local priorities and burden of disease. Funding agencies and international donors often arrive as ‘saviors’ to fund projects that address their own interests — but this is no longer acceptable. Such funders, from the global north and global south, need to examine their practices and systems that result in funds benefiting institutions in high-income countries, which almost always control the purse strings.

Fourth, universities need to focus on impact and reconsider how academics are incentivized in research. A system of rewards for allyship, collaboration, improved health practice, reduced mortality and improved quality of life would be transformative for countries in the global south, rather than the current system that values individual awards, publications and grants.

Fifth, countries in the global south should focus on capacity building and enhancement so that there is greater diversity, equity and inclusion in global health. The old paradigm of elite global north individuals and institutions running projects in the global south must change³.

Sixth, reimagining global health requires addressing the intersecting systems of privilege and supremacy that continue to block equity and justice. Inequities are not only about the needs and concerns of the disadvantaged, but also the systems (in the global north and global south) that create disadvantages.

Seventh, leaders in the global south need to create the conditions that enable scientists in their countries to take ownership of their fields, claiming the space and global leadership that is proportional to the size of their populations and the scope of the fundamental challenges they face.

Eighth, global health advocacy and activism must be championed. All decision-makers, scientists and concerned citizens must continually question the skewed ways in which global health is being studied, taught, funded, researched, driven, designed and implemented. The accountability and reshaping of power dynamics are at the heart of all proposals for change.

Ninth, leaders in the global south need moral courage to stand up for and practice what they consider ethical, moral behavior when faced with a dilemma, even if it means going against countervailing pressure to do otherwise. Moral courage is found at the nexus of principles, risk and endurance. Corruption, careerism, nepotism and tokenistic actions do huge harm to societies in the global south and keep people oppressed.

Lastly, countries in the global south must identify their own priorities and define, fund and implement them — and not be reactionary to the politics of the global north. If African nations, for example, had stepped up and taken ownership of HIV treatment in the region, a rollback of PEPFAR would have limited impact. If Africa had a regional vaccine-manufacturing system, the continent would not have been left behind during the COVID-19 or mpox crises.

Ultimately, governments in the global south must come to the realization that the prosperity of their people lies not in the hands of the US White House, but in their own agency, development and self-reliance.

Competing Interests

N.N. is president and CEO of the South African Medical Research Council.