Writing the Next Chapter in Global Health:
We Can Decide the Outcome Together
Dr. Lieve Fransen, Member, Fast-Track Health Board of Advisors
In these challenging times, silence is not an option.
Health advocates globally, including Europe, must actively champion policies that are rooted in scientific and social evidence, to achieve better health outcomes and drive health security for all. It is our professional and moral responsibility to amplify the voices of people who are marginalised and silenced. Advocating for health equity and recognising health as a universal human right must remain our top priority. Supporting decolonisation, shifting power dynamics, and reducing aid dependency are essential components of this mission.
Towards a Brave New World?
Following the COVID-19 pandemic, I had hoped that our planet’s shared recovery might herald a new era of solidarity and partnerships in global health. A future in which advancements in technology such as artificial intelligence could accelerate transformative progress towards a healthier and more equitable world. Uniting to improve health and wellbeing for all might become a defining mission of our time.
COVID-19 thrust global health to the forefront of international political discourse. The pandemic demonstrated how it was not a lack of science but poor political decisions, including those in highly developed countries, that seriously harmed people. Our shared experiences underscored the need for more effective and equitable strategies to prevent and respond to pandemics, backed by more informed political decision making in public health and security. Some progress was being made.
Then came the US election in November 2024.
On his first day in the White House, in January 2025, President Donald Trump signed an executive order to withdraw the United States from the World Health Organization (WHO). His administration ended the US Agency for International Development (USAID) as an institution, fired most of its staff, and cancelled payments due. It reinstated the Global Gag Rule, jeopardising the health and rights of women and girls around the world, and is rolling out what looks like a loyalty test for charities, nonprofits, and United Nations agencies receiving US funding. Among the 23-question probe you will be asked, “Have you ever worked with groups linked to communism, socialism, or anti-American beliefs?”
The speed, scale and cruelty of these decisions created the intended shock and awe among many in the US and globally. For now, responses have been slow, and unable to save the people or institutions targeted. When the approach is “flood the zone,” the impact is almost overwhelming, and it’s difficult to focus one’s attention. These new realities shocked me personally, and professionally as a long-time global health practitioner and policy maker. I needed to act, to add my voice to the rising clamour. And
I sought parallels in recent history, to try to understand what may eventually stop such political decisions from harming people. I remembered a phrase from the period of McCarthyism in the 1950s: “Have you no sense of decency?”
That phrase was first used during televised hearings in 1954. The period, and that politician, were characterised by reckless and unsubstantiated accusations, and vocal public attacks on political opponents. The phrase still resonates today as a powerful rebuke against unethical, cruel or harmful behaviour. I will return to this later. But first, 70 years on, here are three examples of what “no sense of decency” looks like today.
A New HIV/AIDS Crisis
I was deeply disheartened to see the abrupt cancellation of USAID contracts in Africa, leaving thousands of HIV/AIDS patients without treatment. When I took a call seeking advice on this crisis, I was transported back to the grim realities of the 1980s and 90s. Then, treatments for HIV were either unavailable or unaffordable in developing countries, with a devastating loss of life. It was only through the tireless efforts of activists and institutions, and international negotiations with pharmaceutical companies, that life-saving treatments eventually became accessible. Global health initiatives such as the Global Fund and US President’s Emergency Plan for AIDS Relief (PEPFAR) played a pivotal role.
The scientific community of more than 500 HIV doctors, researchers, scientists and public health experts gathered at the 2025 Conference on Retroviruses and Opportunistic Infections (CROI) in San Francisco wrote to the US Secretary of State Marco Rubio calling for “an urgent reversal of recent decisions by the Administration that are doing catastrophic harm to the global and US response to the AIDS pandemic.” The signatories wrote that the termination on 26 February 2025 virtually eliminated all PEPFAR programming being implemented by USAID, and that ending US-supported malaria and tuberculosis programmes will “result in millions of preventable deaths around the world while decimating global progress over the last 25 years.”
In time, recent policy decisions may be proven illegal in US courts, but the human suffering and loss of lives happening right now cannot be reversed by any court order.
There is an example of good news, however, from South Africa, where government and a vibrant civil society are responding fast, with plans to bolster health and defence budgets. The 2025 budget allocates an additional 28.9 billion rand (USD $1.5 billion) for health spending, enabling the hiring of some 9,300 medical personnel and 800 newly qualified doctors. This increase is vital, as South Africa – home to the world’s largest HIV-positive population, with 5.5 million people relying on antiretroviral drugs – is under immense strain following the demise of USAID funding.
Compromising Free Speech and the Scientific Method
Another development that shocked me is highlighted by an anonymous letter from a US federally funded researcher published in the British Medical Journal (BMJ) on 12th February 2025. The author expresses anger and despair over a directive ordering all US federal workers to avoid using specific terms such as biased, women, advocacy, LGBT, gender, and social inclusion. The writer laments how
such censorship compromises free speech and the scientific method, which are essential for policymaking and evidence-based decision-making.
The day before I wrote this article, the New York Times published an extensive list of restricted words commonly used by policymakers and scientists, underscoring the chilling effect this has on intellectual freedom. The US Centers for Disease Control and Prevention (CDC), a longstanding global authority on public health, has been instructed to retract articles from medical and science journals, a move described by BMJ as “sinister and ludicrous.”
These alarming developments are taking place as the United States itself is struggling with bird flu and measles epidemics, and as Africa is continuously confronted with major threat that could spread globally. The scientific world is already navigating an environment that is increasingly hostile to science, vaccines and the development of a pandemic treaty.
A Critical Year for Multilateral Global Health Institutions
Just days ahead of a pledging summit that was scheduled for this March, to be co-hosted by the European Union and Gates Foundation, Gavi, the Vaccine Alliance, announced it would be postponed. This replenishment event is necessary to raise the USD $9 billion required for its next five-year strategy. According to a source, “The European Union is currently preoccupied with geopolitics” – suggesting global health priorities are being sidelined.
While such a delay creates uncertainty, it highlights a broader trend: the erosion of the commitment to global health funding. This may not be the only institution impacted, with this year critical for multilateral global health institutions: 2025 brings an unprecedented convergence of funding cycles for Gavi, the Pandemic Fund. the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and PEPFAR. In the United States, bipartisan support for global health funds and institutions has been challenged as conservatives question their alignment with US security objectives and, in Europe, donors are redirecting funds to pressing domestic issues such as defence, security and migration.
Opportunities from Chaos?
These are just three examples that have shocked me in recent weeks. There are many more, seemingly daily, too many to enumerate here. And such changes are not only coming from the USA; the UK government recently announced a cut in foreign aid so it can ramp up defence spending. So where does this leave us? A strange thought occurred to me: what if this current crisis might have some positive effects on transforming our global architecture in health?
Global health has been evolving for many decades, from the rudimentary medical practices of a colonial era to today’s international health systems, demonstrating a dynamic interplay of science, politics, solidarity, and interdependence. This evolution has brought both ground-breaking achievements, such as the eradication of smallpox, and enduring challenges, including the ongoing battles against HIV/AIDS and the COVID-19 pandemic. Just as the new US administration is overturning existing notions of global geopolitics and diplomacy, in particular the so-called “Pax Americana” that has existed since 1945, global health care and humanitarian provision are undergoing similar radical change. The outcome is uncertain. But one thing is clear to me:
The need for true leadership at country and regional level, increased self-reliance in health, and diverse international partnerships has never been greater. These are ideas and approaches that I have expounded for many years.
Before January 2025, it was already becoming clear that the donor-dependent models used to deliver global health in the past were reaching a point of no return. Transformation of those models has been discussed for more than a decade but will require a transition period by first putting in place alternate financing sources, and processes that deliver for the most vulnerable populations.
Deeper partnerships and improved collaboration between and within regional blocs of low-income countries, and a greater role for civil society, may hold the key.
Less Aid, Less Dependency?
Is what we are now experiencing simply a logical progression, all be it an acceleration, of a trend that has existed for some time? Calls to reduce reliance on external development aid have grown louder since the COVID-19 pandemic, and many donor countries are scaling back their contributions. While official development assistance (ODA) declined during the pandemic for most health-related line items , it grew massively for disease surveillance and a new line-item covid-19. Thus, ODA for health skyrocketed in 2020, but the increase was targeted to just those two activities while other ODA health line-items fell. ODA for nutrition fell by nearly 11% and has not recovered since. Basic health fell by nearly 35% and has also not recovered to pre-COVID-19 levels.
Aid dependency has declined but private, philanthropic and national funding sources have not increased sufficiently to fill the gaps. This has left many communities without access to basic necessities such as clean water, sanitation, and healthcare services. Drastic cuts in development aid by traditional donors exacerbate the problem. The US has reduced aid by an estimated USD $60 billion. The UK has cut GBP 6 billion. The Netherlands plans to slash EUR 8 billion over 2025-2028. Germany is considering reductions of up to EUR 20 billion. And so on.
In Europe, geopolitical tensions are driving remilitarization, requiring significant budget reallocations at the expense of ODA and global health. COVID-19 further exposed the sector’s failures, particularly its inability to support the Global South equitably. Between 2021 and 2023, development assistance for health in low- and middle-income countries plummeted from USD $84 billion to USD $64.6 billion. At the same time, these countries face escalating debt burdens, with interest payments more than doubling since 2019.
And despite speculation that countries like China might step in, its contributions remain limited, providing only USD $5-7.9 billion in aid in 2022, with only a small portion allocated multilaterally.
Transforming Global Health: An Ongoing Journey
The transformation of global health models and institutions is a never-ending process, particularly considering the huge reliance of many low-income countries on foreign aid and the consistently low commitments of national budgets for health in many of the same countries. Geopolitical realities have played a role but, often, global health partnerships have been able to transgress deep political
divisions. And over the last few decades, the increasing involvement of civil society in international health governance has marked a significant shift in global health policy.
I have long been convinced that health and wellbeing possess a unique “soft power” to foster greater collaboration and transformation, even amidst geopolitical turmoil. My own journey affirms this belief. When I worked as a medical doctor in Mozambique in 1974-1979, the world was similarly polarised by the Cold War, with divisions between the Warsaw Pact nations, where I worked, and in the NATO countries where I had grown up. Yet, during this time, the international community united to achieve the monumental goal of eradicating smallpox.
Around 2000, in the aftermath of the 9/11 attacks, the global health and rights communities showed their ability to come together, ensuring that treatments for HIV/AIDS, malaria, and tuberculosis became more accessible and affordable. The United States and the European Union agreed to disagree, as US Health Secretary Tommy G. Thompson said, regarding reproductive health and came together for the global good.
This collaborative spirit led to the creation of the Global Fund that, in its first year, operated from EU offices in Brussels. Amid the geopolitical aftermath of 9/11 and wars in Iraq and Afghanistan, I was honored to receive the Jonathan Mann Award from the International Association of Providers of AIDS Care (IAPAC) for my work on health and human rights. Meanwhile, Europe rallied against the Global Gag Rule implemented by President George W. Bush’s administration, establishing a decency fund to address gaps in support for sexual and reproductive health caused by the gag rule.
In more recent times, I have been advocating to improve the governance architecture of the Global Fund by increasing the voice of Africa on its Board. But recent developments remind us how fragile progress can be and how this time, global health seems unable – as yet – to break away from the negative geopolitical turmoil and instead finds itself the target of attacks by the US administration and some of its likeminded allies.
The World Moves Forward
While reducing reliance on ODA is essential, the transition could and should have been carried out in a far more deliberate and compassionate manner. Many in the developing world have long been calling for a renewed focus on prevention, primary care, and community health, and African nations and the BRICS provide examples of change now under way.
Delegates at the recent Sixth Africa Health Agenda International Conference (AHAIC) in Kigali explored ways to maximise healthcare delivery with limited resources. The consensus was clear: traditional aid is no longer reliable in the face of sudden cuts by the US and incremental reductions by European donors. Prioritising essentials could significantly cut future healthcare expenses. Africa can succeed: not in spite of the international community’s unreliability or apathy, but because of it.
With COVID-19 revealing the dangerous vulnerability of global pharmaceutical production chains that rely on a tiny number of producers of final products or essential ingredients, successful African countries have been forced to become more self-reliant and take greater responsibility. Such attributes mark out the reformers from the laggards, and the performers from the spectators.
South-South collaboration represents the most viable path. BRICS nations are important in this regard because they have the resources, technology and expertise to strengthen regional manufacturing capacities and to reduce the dependence of poorer countries on imports from the Global North. Brazil, for example, has a long tradition of producing vaccines in the public sector and is in discussions with the African Union (AU) about developing the continent’s manufacturing capability. This cooperation must expand if the AU is to meet its target of increasing vaccine manufacturing in Africa from the current 1 percent of local needs to 60 percent by 2040.
What Should Europe Do?
As Europe navigates this period of significant geopolitical transformation and rising illiberalism, the foundational principles of our democratic societies face unprecedented challenges. Ultimately, it will take leadership, political will, and global collaboration to counter cruel decisions and to create positive change for a new reality.
In the short term, Europe must act swiftly and effectively to support countries and communities left vulnerable by the US withdrawal from global commitments. Furthermore, Europe should help lead the charge in overhauling the global health architecture to address systemic challenges.
Building on its strengths, Europe should foster respectful partnerships with poorer countries and communities in Africa and other regions. This includes fortifying healthcare systems and promoting the regional manufacturing of medicines in under-served regions.
While ODA and humanitarian aid remain indispensable, Europe needs to focus on policies that are aligned with national priorities. Actions should be co-created with local communities and stakeholders, ensuring they are addressing specific needs; locally designed programmes with strong in-country ownership can enhance each nation’s capacity, resilience, accountability, and leadership.
Europe must advocate for improved representation of aid recipients and their governments in global institutions and partnerships. At the same time, civil society actors need to forge new alliances to safeguard liberal democratic foundations against the growing threat of anti-democratic forces.
Lessons from the Past: McCarthyism
Back to the phrase “Have you no sense of decency?” Europe’s response to McCarthyism in the 1950s was largely observational, with limited direct intervention. Although primarily a US phenomenon, McCarthyism had global repercussions, reinforcing the Cold War narrative of East versus West. It fostered a climate of fear and suspicion that influenced international relations and domestic policies for years.
In the United States, the turning point came during the televised Army-McCarthy hearings in 1954. US Sen. Joseph McCarthy’s aggressive and baseless accusations were publicly scrutinised, and his bullying tactics exposed. A pivotal moment occurred when the Army’s lawyer Joseph Welch asked McCarthy, “Have you no sense of decency, sir?” This resonated with the public and marked a shift in opinion.
Journalist Edward R. Murrow further eroded McCarthy’s credibility, and the US Senate censured him later that year, effectively ending his influence. Broader societal changes, including the US Supreme Court rulings protecting civil liberties, also contributed to the decline of McCarthyism. This period
thrived on fear, suspicion, and an erosion of trust in media and institutions. It serves as a reminder of how public discourse can become polarised, with lies and accusations overshadowing facts.
However, history also shows that such periods can end when people demand accountability. Today, European nations, while often critical of US positions, are focused on bolstering their defence and security, and addressing internal political challenges, not least the “collapse” of the centre and the rise of the far right. Yet, it is crucial that Europe and its citizens do not turn away and remain silent when confronting threats to our global health and wellbeing.
Standing Resolute
These are dark days. But despite recent setbacks, our collective commitment to improving global health and to saving lives must remain steadfast. The work continues, in multiple areas, thanks to strong collaborations between diverse funders, national governments, civil society, and a range of local and global partners – some forged more than 50 years ago. Today, more than ever, the world needs innovative partnerships and fresh thinking to tackle the global health challenges that we face. Whether as a funder, implementing partner, or government seeking expertise, let us join forces to write the next chapter in global health history.
Lieve Fransen, MD, PhD, is a former senior adviser to the European Policy Centre on Health, Social, and Migration policies. Between 2011 and 2015 she was the Social Policies Director in the Directorate for Employment and Social Affairs for the European Commission. Before that she was Director for Communication and Representations in the European Commission’s Communication Directorate, and from 1987 till 1997 she was Head of Unit for Human Development in the European Commission’s Department for Development. She is currently based in Brussels, Belgium.