How Trump is affecting health around the world
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Hello, welcome to The Lancet Voice. It's February 2025 and I'm your host Gavin Cleaver. Today I'm joined on co-hosting duties by Miriam Sabin, North American Executive Editor here at The Lancet, and we're talking to Professor Gavin Yamey, who is the Director of the Centre for Policy Impact in Global Health at Duke University.

We'll be discussing the recent and shocking changes in US global health policy under President Trump. From sweeping executive orders to a 90-day freeze on foreign aid, we'll explore the severe implications these changes have for global health programs and the potential for disease resurgence around the world. Join us as we try and make sense of the chaos and confusion of the past few weeks and discuss the challenges and hopes for global health in the years to come. Let's get started.

Professor Gavin Yamey, thank you so much for joining Miriam and I today on the podcast. It's a real pleasure to have you with us. Obviously, you can't get away from the news at the moment about Donald Trump's presidency and his takeover of the US. It's only been a few weeks. It feels like a lot longer than that. What stands out for you the most in the first couple of weeks of his presidency?

Well, first of all, thanks so much for having me on the podcast. I wish it was under happier circumstances. I think the thing that stands out the most for me really is how sort of sudden and severe

and how kind of shocking the changes have been, the executive orders have been coming fast and thick. Each new one leaves many of us kind of scrambling to understand the implications. I think that does seem to be somewhat of a deliberate strategy, right? To shock people into kind of discombobulation.

so that you're not really sure exactly what's going on. It's very hard to find information. Many of the federal websites have gone dark, so you can't even get any actual information, even if you try and find it. And so certainly for those of us working in the global health arena, the last two weeks have been extraordinarily unsettling, chaotic.

and really quite hard to understand or grasp. We're in very unprecedented territory. There's really been nothing like this, I think, in modern US history. Yeah, I sort of have this desire to live in precedented times by this point. In global health terms, what's kind of stood out for you the most in the first couple of weeks?

Well, it's not even the first couple of weeks, to be honest. It was day one of the Trump presidency when he issued a sweeping 90-day freeze on all U.S. foreign aid, almost all U.S. foreign aid. There were a few exceptions, military aid for Egypt and Israel and Iraq.

food assistance, although our colleagues on the ground say that have been major destruction to food assistance. So this 90-day freeze accompanied by work stop orders. So our colleagues on the ground involved in implementing programs, service delivery, working at NGOs, clinics, or doing clinical trials or health research, they got stop work orders. They were told to down tools,

you know, to fire staff, to shutter clinics, to turn patients away, um,

And that has caused absolute mayhem, as you can imagine. So that's certainly true for global health programming. It has led to interruption of HIV treatment services, for example, malaria control programs, disease control programs targeting MPOCs, Marburg, childhood diarrhea control programs. Oxygen is not being delivered in many parts of the world.

Malaria bed nets, not sitting in warehouses, not going out to sub-Saharan African countries, and all of this interruption and disruption and chaos

is, I'm afraid, already causing increased disease transmission. And if you look at the history of sudden disruptions to disease control program, we are very, very likely to see major disease resurgence and sickness and deaths. Our own center here at Duke has done a lot of research on the transition of countries out of foreign aid

And when that's done very suddenly and precipitously, you see disease resurgence. So we know that this is going to happen, sadly, and it was entirely avertable. 90 days sounds like quite a short amount of time, doesn't it? But in these timeframes, it's quite a serious interruption.

Yes. I mean, let's not forget, for example, that if you stop people's antiretroviral therapy, obviously they can become sick, their viral load goes up.

transmission increases as a result, you can interrupt the prevention of mother-to-child transmission, and crucially, the longer that you force treatment, the more likely that patients are to develop resistant HIV. But they then can't go back on the same medicines and they have to go on to more complex and more costly second or third line regimens. You also see potentially rapid malaria resurgence when you stop

malaria-controlled provenance, when you stop insecticide spraying, when you stop the delivery of these long-lasting insecticidal bed nets, when you stop doing intermittent presumptive therapy for children or pregnant women, you can start to see resurgence quite quickly. And if you look at some of the cuts that have happened and some of the reporting on the ground,

The Ugandan National Malaria Control Programme, as a result of suspending USAID, has had to suspend spraying insecticide into village homes, and they stopped giving out bed nets to pregnant women and young children. So we're going to see malaria resurgence, no doubt. And there's also just a tremendous amount of confusion and chaos

around the so-called wave. Marco Rubio, Secretary of State who oversees USAID, has been under enormous pressure from HIV activists, from academics, from implementers, from many of us working in the global health world. We've been writing to our senators and contacting the State Department. He's been under a lot of pressure

to at least allow continuing funding for antiretroviral medicine. So he initially issued a waiver last week, but the reality is that the language of the waiver was very confusing and it wasn't very specific. And our colleague in Lower Middle East said they were under stop work orders, that this waiver wasn't helping them at all. So a couple of days ago, just last Saturday, he issued a further memo

trying to clarify that yes, antiretroviral medicine could continue as well as prevention of mother-to-child transmission services.

But it's still not clear that these stock work orders have been dissolved. And on the ground, there is still a lot of disruption and chaos and confusion. And of course, the waiver is very limited. It is temporary, very narrow, doesn't apply to many of the things that I was talking about earlier, from maternal and child health to malaria to control of outbreaks like empocked

Marburg, and that's not the way that you should ever proceed in the financing of disease control programs. You should never suddenly switch off the tap. The US spends around $70 billion a year on aid.

and around 40 billion of that is through USAID. A lot of that is for humanitarian assistance and for global health. Global health is about 12 billion of that. The idea that you can suddenly switch off

That amount of financing and not the diseases research, people starving, is ludicrous. Countries can't suddenly find $70 billion overnight. That's just not how it works. That's not how the financing of disease control programs works.

And so the effect has really been quite apocalyptic, to be honest. And then if you add in the withdrawal of the US from the WHO, CD staff being banned from discussions and contact with the WHO, the essential dissolution of USAID, USAID staff have been told to stay at home with yellow tape across the

office doors, you know, it's kind of mind-blowingly apocalyptic right now in the humanitarian and global health space, I would say.

So, Professor, let's dig a little further into the domestic financing landscape. You know, you had talked about that you've studied for a long time what the outlook is for transition for countries to take on more and more of their own financing needs for procurement, for services, for outbreaks. If

If PEPFAR and if USG funding were to remain frozen, you know, past 90 days or even significantly cut back, what do you see as, you know, the outlook and what lower income countries and then lower middle income countries could do in

And what do you think the donors could do, OECD donor countries, to also help? Thank you, Miriam. And that's a great question. Yes, our center here at Duke, Center for Policy Impacting Global Health, we have been working with universities and think tanks in six lower middle income countries.

Ghana, Kenya, Nigeria, India, Sri Lanka, and Myanmar, to study the transition of low- and middle-income countries out of foreign aid, also called graduation. Those six countries are all on the transition journey. And it is absolutely true that transition is at the heart of decolonizing global health.

We all want every country in the world to be able to finance and control and run its own health sector, right? We want a post-AID world. But the reality is, from all the research that we've done and many other scholars have done, transition has to be done in a very careful way. Donors are supporting the transition process, including the US, by the way. I mean, PEPFAR, if you look at its latest five-year strategy, it has sustainability as a central pillar.

So PEPFAR is working with countries to help them gradually increase their own domestic financing and gradually, carefully increase ownership of their own national HIV control program. The key word I think there is gradually, and our research has shown very clearly that if you hurry it, and if you don't do it in a careful, safe, well-planned way,

you get shocks and disease resurgence and chaos. And you particularly see disease resurgence in vulnerable groups. I mean, I think the best example of this, we did a study on transitions out of HIV programs. And I think the best example of this was if you look at the first wave of global fund transition. In other words, the first group of countries that lost external support from global fund.

That was at a time when transition wasn't necessarily being done in a sort of careful, planned way. The Global Fund left Romania precipitously in 2010. There was no plan put in place by the Romanian government to pick up funding of HIV services, particularly for vulnerable groups.

And it was absolutely catastrophic what happened. If you look at the prevalence of HIV in people who inject drugs, in 2009, that prevalence was about 1%. So the year before the Global Fund suddenly leaves in 2010, the prevalence was 1%. And just four years later, it's risen 53%.

There were no services in place for reaching people who inject drugs, men who have sex with men, sex workers and other vulnerable groups. And that's something we have also learned from our research, is that safe, careful, well-planned transition

must include a plan for reaching so-called key populations or vulnerable groups. Men who have sex with men, people who use drugs, transgender people. In some places that means refugees, women and children. Very often, successful transitions

Taking into account vulnerable groups has involved so-called social contracting, where the government contracts with civil society groups, non-governmental organizations, and says, let's make sure service delivery to these groups continues when the donor leaves.

And here, the government says, here is government funding for you, the CSOs or NGOs, to continue to provide prevention and treatment services to those vulnerable groups. And we've seen that in places like Mexico, places like China, where that kind of social contracting was very effective and you didn't then see the HIV prevalence suddenly rise in the vulnerable group after donor exit. Be careful.

planned, well thought out, gradual transition to avoid these kind of shocks. You also asked what else can the rest of the international community do? Obviously, we hope that there are going to be other donors that can step into the brief, that can provide emergency financing to fill this gap. But again, for donors to suddenly find $70 billion in aid,

is extremely challenging. But, you know, all eyes are on, you know, the Europeans, all eyes are on foundations that could potentially step up and increase their support for humanitarian assistance and for development assistance for health. But again, you know, filling these massive funding gaps, this massive overnight freeze is very challenging. It's a very logistically hard thing to do. Lower middle-income countries right now are reeling

and facing the risk of disease resurgence from this kind of sudden financial unprecedented shock.

The Marco Rubio waiver that you referred to about PEPFAR programs doesn't say explicitly, but appears to suggest that key populations programs in general, also orphans and vulnerable children programs, will not be included. And as you were saying, you know, this is incredibly important for disease transmission, particularly in Eastern Europe and Central Asia, where HIV infections are increasing.

have been increasing for a period of time because of poor legal and policy frameworks in a number of countries. So I guess it also depends on which country is transitioning and how supportive they are of their most vulnerable populations. Right.

Right. I think that's exactly right. And I think, Myriad, we're all trying our best to pass the language of waiver and our understanding, my colleagues here at Duke, with deep expertise at PEPFAR,

They agree with your assessment that this memo does not appear to cover a whole range of prevention activities, including prevention with people who inject drugs and orphans and vulnerable children. So here's the thing. I think that we could have a long and very important debate today

on the pros and cons of foreign aid. That debate has gone on for decades. I happen to think there's very good research evidence showing that external assistance has had a demonstrable impact on improving lives and well-being. Our estimates that it has saved more than 25 million lives, for example. So I think there's a very strong case to be made that development assistance for health in particular

has had an impact, although it is not without its own problems. You know, the amount of control, the power that donors have over countries, you know, to shape national priorities. You know, there are unintended consequences. There are studies that have shown, for example, that external financing can lead countries to reduce their own

domestic financing of health so-called aid substitution so those impacts those negative impacts have also been well described having said that i think there is one area myriad but you've already alluded to where you could argue that donors have been very successful and that is in insuring

that programming reaches vulnerable groups. So if you are a country that wants global funding for your HIV control program, for example, you are required in your proposal to have a plan for reaching key populations, vulnerable populations. In other words, as a requirement of getting your funding,

you have to reach the populations that prevention and treatment services. So donors have enormous amount of leverage with their external assistance to ensure that governments have a plan to reach those populations. When donors leave, when they exit, you know, after they transition or graduate out of aid, that guarantee has gone and that leverage has gone.

And so to my point earlier, I think the key is during the transition process, which typically can take, you know, a decade or more, there is the opportunity, there is the time where donors and countries in partnership can have that conversation, where donors, you know, are still partnering with countries that still have leverage to say this transition is going to require

a transition that includes a plan for reaching these populations. We, you know, we the donor may well be aware that it's a country that has historically marginalized these groups or shown prejudice towards these groups. And that

makes it even more important for a plan to be put in place. And there are now a whole range of so-called transition planning tools, transition readiness tools, that pretty much all donors and countries are now using to kind of manage this decades-long, or sometimes even more than a decade-long process. And that suite of tools, checklists,

helps you identify not just the prevalence of the disease, the epidemiology of the disease, how the disease is being transmitted, the financing situation, the country's fiscal space, fiscal affairs, but also the human rights environment and the gender environment and the status of key populations. And those tools will then kind of flag or highlight

where there are gaps well ahead of that day when the donor finally exits and that donor doesn't exit suddenly typically countries are being asked to spend more and more year on year on year if you imagine that happening say over 12 or 13 or 14 years the country doesn't then face a sudden cliff you know in a dozen years they've been spending more and more

And during that process, if gaps have been identified around this human rights arena or gender arena, those gaps can then be filled. The key is that this is done in a very planned, very sort of conscious, very orderly way to avoid the kinds of catastrophes that I mentioned earlier.

You're one of the lead commissioners on the Lancet's Investing in Health Commission, and that looked at how we can reduce premature death by 50% by 2050 around the world. Has anything that's happened in the last two, three weeks kind of changed the assumptions that you had going into that commission? That's a great question, Gavin, and it has already arisen. We did a launch of our new Lancet Commission on Investing in Health report, which is called Global Health 2050.

We did a launch at the University of California, San Francisco. It was in the first week of the Trump presidency. And, you know, the aid freeze had been announced. And there was enormous consternation about, you know, what that would mean for the future of global health. And he had already announced his various picks to lead U.S. health agencies, including, you know, his pick for

for Health and Human Services Secretary, HHS Secretary, RFK Jr., arguably the world's most notorious, extreme and dangerous anti-vax activist, who's also an AIDS denialist. And so there was an enormous amount of concern for the future of global health, the future of US public health. And naturally, the question arose at its launch. You're talking about countries being able to halve premature death

death before the age of 70 by 2050 from what we argue would be a pre-pandemic 2019 baseline. With all that's happening in U.S. global health policy, the sudden shocks to U.S. domestic health, do you still think that is feasible? That is the question that arose at this launch a couple of weeks ago.

How I approached that when I was asked that question, I was very lucky to give the opening keynote summarizing the key messages of the report, was that if you take a long-term view, you can absolutely make the case that there will always be setbacks, but that the history of global health is a history of progress in the face of setbacks.

So if you look at the timeline that we're talking about for halving premature mortality, 2019 to 2050, so 31 years or less, from 1970, 37 countries halved their premature mortality in 31 years or less, including seven of the world's most populous countries.

And those seven countries, by the way, were very different geographically, economically, politically, and they had very different kind of baseline premature mortality rates.

And those countries also faced various kind of political challenges, political vicissitudes. They continued to make progress. So when we look back historically, and so we imagine the same would be true projecting forward, there are going to be setbacks, but that you can still continue to make progress on premature mortality in the face of headwinds. If you look at

the uh some sort of africa region and if you look at the rates of of premature mortality those have been steadily decreasing the probability premature death death before 70 has been steadily decreasing

over the last few decades. It rose at the peak of the HIV-AIDS pandemic, and then it started to fall. And actually, the rate of fall is now faster than in many other regions in the world. So they had a setback, they had a challenge, and yet they were able, in the face of that challenge, to then continue to make headway and actually to accelerate. What our report shows is that that's possible through a

a focus on the conditions that are the biggest cause of premature death. We identified 15 of those conditions: HR infections and maternal and child health conditions, seven are non-communicable diseases and injury, and continued investment in research and development. If you look at child mortality, for example,

Around 80% of the decline in child mortality in lower and middle-income countries from 1970 to 2000 can be explained by the diffusion of new health technology, vaccines, medicine, diagnostics.

And the pipeline right now for global health, for medicines, vaccines and diagnostics, is incredibly rich. And we anticipate from our own modeling research, from looking at what's in the pipeline and sort of modeling the likely launches, that we could see something like 400 or 450 new pools before 2050 that could also have this accelerating effect.

in reducing premature mortality. We've got three TB vaccines now in late-stage trials. Last year, we saw probably the most important HIV breakthrough in a very long time, led to Capavir.

which has an extraordinary impact in preventing HIV transmission. So we can continue to be optimistic on the health technology side. Again, we have been in the setbacks, the US aid freeze, let's not forget, doesn't just free services and service delivery and humanitarian aid, it also freezes research and clinical trials.

So, you know, that's undoubtedly a setback, but in the long term, we will overcome those setbacks and we will continue to see progress, no doubt. Do you think the role and the health of the pharmaceutical companies now, the many startups that now exist and foundations now,

might be able to fill some of the gaps that, for example, NIH held and holds still globally as the world's leading research institution, the most research dollars. Well, again, Miriam, the U.S., as you just said, is the largest public funder of biomedical research.

The NIH has been historically extraordinarily kind of, you know, bipartisan in the support that it receives. The NIH has had bipartisan support year on year. As, by the way, has U.S. foreign assistant in PEPFAR has received extraordinary bilateral support. It was founded by George W. Bush, as was the U.S. President's malaria initiative. You know, those are two of his signature achievements.

And that's why in many ways what's happening right now is unprecedented because the NIH under fire, the National Science Foundation under fire, Global Health under fire, US assistance for global health under fire, PEPFAR under fire, the present malaria initiative under fire. These have all traditionally been areas of bipartisan support. So many of us hope that that support returns.

We can only hope that this freeze is temporary. The domestic federal spending that Trump put on hold that have been challenged in the courts, that spending had to continue.

There is still a lot of uncertainty around whether grants for research on what the Trump administration, I guess, would call kind of woke science, whether that research is going to be frozen. You may have seen yesterday reporting on the National Science Foundation, a federally funded science agency that supports a lot of science research here in the U.S.,

The National Science Foundation is being asked by the Trump administration to review grants for words like equity, women, gender, racism, etc. And there is a huge amount of fear that our research in health and scientific arenas that is related to core concerns

around equity, around injustice, around racial and structural causes of illness, around climate change and health, around LGBT health. There is great concern that the Trump administration is going to try and defund those areas. So

We are all waiting to see how that plays out. The situation right now is really almost minute by minute, you see a headline and you have to sort of kind of try and understand what's going on, you know, whether it's the CDC or USAID or NSF or the Department of Education. It's really right now just trying to keep up with this kind of fire hose of bad news.

affecting science and health. Sure, I hope that other research funders step up to fill those gaps, if there are indeed gaps in funding critical science research and critical health and biomedical research on inequalities in health, on climate change in health, on LGBT health. I really hope other funders step into the breach, if there is a breach.

But again, depending upon the size of the funding gap, that's not going to be easy, immediate and straightforward. But I would love to see other funders step up. And I would also love to see universities and research institutes continue to support and be proud of those claims of research. We do a lot of that kind of research here at Duke, and I hope that research will continue

And because it's absolutely central to what we do. If you look at the definition of global health, it has equity at its heart. The idea that you could either study global health or be part of the global health enterprise, global health landscape and ignore equity is preposterous. You know, it is at the very heart of what we do.

I wanted to ask you actually to finish up, what in your opinion were the kind of the most pronounced effects on global health from the first Trump term? And how does this feel different? So I think during the first Trump term, my sense is that there continues to be very strong bipartisan support for global health, the arena in which I work, and for NIH. And so for example, Trump said he wanted to cut the NIH budget

But actually, during Trump 1.0, the NIH budget went up. Congress appropriated a larger budget. It is true that in his final year, Trump withdrew the US from the WHO, but that process requires a year. And so by the time Biden became president, he reversed that decision. So that withdrawal never went through. This time round, he's done it right at the start of his term.

And he's gone further by actually instructing officials at CDC to have no communications with WHO. That seems extraordinarily dangerous to me. This time around, he has issued these extraordinarily extreme, harsh, sudden executive orders and work stop orders that have immediately led to

clinics and hospitals and trials, NGOs to down tools, hire people and to stop delivering services and stop doing trials in a way that he didn't before. He's using the power of the pen in this very extreme and very disruptive way. That feels very different to the last time. And it feels, unfortunately, as if the sort of bipartisan support

for agencies like NIH and for signature initiatives like PEPFAR or the present malaria initiative. We don't see that now. We're not seeing Republicans taking to the airwaves and saying we must do what we can to protect NA or to protect PEPFAR or PMI. We're just not seeing that this time around. It seems to have sort of cowed the GOP into submission. So it really does feel extraordinarily different this time around.

Just to say, despite the hardship and the angst and the confusion that's going on right now, I really appreciated talking to you today, Professor Yamey, because, you know, part of what you do is to be a seer into the future. That has been a lot of your work, right, to project, to think about what might happen, you know, by the time of the SDGs or into 2050. And I also heard a lot of hope in what you discussed.

You know, as you said, the progress occurs even in the face of all this adversity if we take a long-term view. And I'm personally going to hold on to that thought and hope that it carries me through. I'm delighted that I was able to.

to provide some optimism. You know, I'm not going to lie. You know, it is a very difficult time for many of us, you know, working in public health and global health right now. But as you said, progress is possible in the face of challenge. I've been saying that to my students in the last couple of weeks, and I certainly believe that to be true. And I would also say, you know, to your point about kind of what it is that we do, universities and academics, researchers,

We all have a role to play right now in trying to just lay out the facts using data and evidence and science to say, this is what is happening. This is what we are seeing. These are the likely impacts. You know, we can use the tools of biomedical research and science to say, for example, if you suddenly stop this kind of disease control program, these are the likely effects.

And without being partisan, without getting into the politics, although that's sometimes difficult, but as much as is possible, we can go forward, continuing to lay out the data, the science and the evidence. And I think that's going to be an extraordinarily important role for us to play over the next four years.

I completely agree. And it's great to strike the note of optimism, but also to talk about all the awful things that have been going on the last couple of weeks. So, Professor Yemi, thank you very much for joining us. Thanks, Gavin. Thanks, Miriam. Great to speak to you today. Thanks so much for listening to this episode of The Lancet Voice. If you'd like to find out more, you can go to thelancet.com slash multimedia, where you'll find all of our infographics and videos, as well as all of our different podcast offerings.

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