The U.S. decision to pullout from the World Health Organization earlier this year reflects more than a single dispute with a multilateral body. It fits a broader America First posture sceptical of blank-check internationalism, driven by Covid-era credibility failures, and sharpened by geopolitical strategy in a bipolar U.S.–China landscape.
This realpolitik framing matters. With the closure of USAID, health diplomacy is now squarely under Marco Rubio’s State Department – the first person since Henry Kissinger (1973-1975) to serve simultaneously as Secretary of State and National Security Advisor.
But critics warn—with some justification—that an incoherent American pullback from multilateralism will open space for China – in soft power, biotech, standards-setting, and supply chains.
So far, the Administration has signalled a direction of travel: a stronger role for the State Department in global health security, a tilt toward bilateral arrangements, reduction of waste and aid dependence, and a desire to make health diplomacy an ambassador-level priority.
Yet other opportunities exist for Washington to build something bolder, more impactful, and longer lasting.
First, the Administration needs to create a durable and competent institutional order. From Bretton Woods to the Washington Consensus, the agenda setting power of the U.S. has been dominant for more than half a century. Certain multilateral functions are not irrelevant: surveillance of health risks, technical standards, and rapid information exchange matter.
A U.S. “biological firewall,” as some officials have described it, requires more than disjoined bilateral memorandums. A Five Eyes-style umbrella network could deliver results with greater speed, transparency, and accountability than WHO by working through smaller, high-trust arrangements linked to predictable guarantees— for bio surveillance, lab safety, manufacturing, infrastructure, and delivery.
Furthermore, vesting the State Department with the world’s largest global health program means the workforce needs to rapidly evolve. Diplomats need to speak the language of global health while the health workforce need to learn the language of foreign affairs.
Second, global health diplomacy needs to be more coherently pulled into trade and economic statecraft, with the same centrality in foreign negotiations as the U.S. treats energy security, semiconductors, or critical minerals.
This conceptual rebalancing has begun to take place—from charitable grant-making to strategic commercial diplomacy. China’s expanding Health Silk Road is the alternative model on offer, focused on integrating tech standards and infrastructure into national health systems. So far, Congress has boosted funding to the investment ceiling of the International Development Finance Corporation to $205 billion to offer an alternative to the Chinese Belt and Road Initiative, but it is unclear how much will go to health diplomacy. Following Rubio’s rehabilitation of the Monroe doctrine, a coherent Latin American health initiative, including in Venezuela, would be an obvious place to start.
A broader view also requires a clear China doctrine. America’s longstanding comparative advantage has been the ability to define gold standards that others adopt because they unlock access to markets, capital, and scientific networks. Yet the U.S. has fallen behind in critical areas: China has become the primary source of novel drug candidates and produces most active pharmaceutical ingredients (APIs), including for U.S. markets. Recent policy and legislation have begun to decouple U.S. biotech and venture capital from China – sometimes referred to as “Biotech NATO” – including through the Biosecure Act, reciprocal trade agreements, efforts to onshore API, and outbound investment controls.
But a more mission-focused international reform agenda from NIH, FDA, and CDC in innovation, regulatory harmonization, faster approvals, and clinical trial infrastructure is long overdue. Parallel initiates should consider opportunities for constructive cooperation where interests align—such as countering counterfeit medicines, strengthening transparency norms, and advancing rare disease science.
Third—and the most overlooked—Trump’s health diplomacy should confront chronic disease as a strategic global security priority. For decades, American health assistance has been misaligned with the burden of disease, over-focused on infectious disease while under-addressing the metabolic, cardiovascular, oncological, and mental health conditions that now determine long-term resiliency. This impacts workforce productivity, military readiness, and long-term competitiveness.
Domestic reforms should be incorporated into U.S. foreign policy. While HHS Secretary Kennedy has revised the food pyramid to focus on whole foods, and cleaner food labels and fewer dyes, trade agreements continue to push for preferential access for American ultra-processed foods.
Bold new international initiatives, such as a proposed Alzheimer’s acceleration fund, could outpace the slow speed of multilateral target-setting and ensure America remains the indispensable hub for next-generation diagnostics and therapeutics.
A more transactional, innovation-driven U.S. global health posture is not isolationist. Done well it is statecraft and can significantly improve health around the world. Yet realizing this potential will require a more expansive vision in Washington of what is possible. As Kissinger once famously stated: “Every great achievement was a vision before it became a reality.”
Kevin Bardosh, PhD, is a Senior Non-Resident Fellow at the Foundation for American Innovation in Washington, DC and an Evidence-Informed Fellow at Kellogg College, University of Oxford. He recently served as a Senior Science Strategist in the Office of the Director, NIH.
