“Stop looking north, look to the world”. Can we imagine Global Health without the USA at its centre?

By guest contributors Cristian Montenegro. King’s College London and Universidad Andrés Bello, Chile; and Sebastian Fonseca, University of Exeter, UK; and University of Maastricht, NL.

“Colombia, stop looking north; look to the world.” These are some of the words used by Colombia’s president, Gustavo Petro, in response to U.S. president Donald Trump’s economic threats— themselves a reaction to Petro’s initial refusal to accept U.S. military planes carrying deported Colombian migrants in inhumane conditions. It captures a broader truth that extends far beyond Colombia, migration, and trade, compelling us to confront a more profound question: How should the world respond when a single country’s power and influence are so deeply embedded in global structures that its actions can destabilise entire systems?

Nowhere is this imbalance more immediately apparent than in global health. President Trump’s decision to withdraw the United States (U.S.) from the World Health Organization (WHO) has sparked widespread concern and condemnation across the global health community. Combined with the suspension of PEPFAR, and the uncertainty surrounding the future of the United States Agency for International Development (USAID), the main overseas aid agency responsible for administering humanitarian assistance globally, these actions threaten to disrupt essential programmes upon which millions of lives and livelihoods depend.

This is, by all means, a crisis. It is striking, however, how much of the reaction within the global health community has centred on decrying Trump’s decision, with limited calls to appreciate and confront the profound dependency on U.S. funding and leadership that has defined global health governance for decades. As already argued as part of the decolonising global health movement, while contributing to multiple global health efforts, this disproportionate influence is a structural barrier to achieving equity and justice in the field and in the world. We may be able to count the costs of U.S. withdrawal from global health, but there are costs to U.S. generosity which may be more difficult to count. As scholars and practitioners, we believe this disruption should prompt us to collectively rethink and rebuild global health in ways that decentralise power, diversify leadership, and prioritise fairness. The structural dependency on U.S. funding and leadership is a fundamental barrier to achieving a truly global vision for global health.

Dependency means vulnerability

Regarding academic knowledge production, global health is a highly centralised field, with power concentrated in a handful of actors—chiefly based in, reliant on, or imitating the ways of the U.S. and Western Europe. This dominance extends beyond financial contributions, shaping research agendas, training, methods, publications, and determining programmatic priorities and governance structures. It generates and reproduces unfair knowledge practices that serve U.S. interests primarily, and often at the expense of serving countries and people elsewhere on whose behalf, alongside whom, and for whose benefit knowledge had been produced.

Leaders have demanded structural change in global health for decades. But social structures are, by their nature, built on regularity and expectation. They reduce the uncertainty inherent in social interaction and facilitate the emergence of cooperative action. The disruption of these expectations—whether by withdrawing funds or leadership—exposes the fragility of the entire system. However, it also offers an opportunity to understand what structural change actually involves and the risks it creates. Change of this kind, that is, change that involves structures, requires embracing uncertainty, complexity, and a departure from established routines.

Rechannelling the decolonial critique to imagine a different global health

The critique of global health has expanded over the last 20 years, addressing issues ranging from representation and funding allocation to the epistemological limitations of Western biomedicine. The notion of decolonisation has encapsulated this wide spectrum of discomfort, providing historical context and opening space for Global South voices and practices to enter the debate. The inequities exposed by the pandemic galvanised a decolonial movement in global health, “which fights against ingrained systems of dominance and power in the work to improve the health of populations, whether this occurs between countries, including between previously colonising and plundered nations, and within countries”. In this sense, the movement has expanded a normative debate—a space to reflect on how global health should operate and how it ought to be governed in the light of justice considerations.

The U.S. withdrawal from the WHO shifts this normative debate toward a more pragmatic one. Or better still, it offers a moment for this movement and other alternative networks to establish new international connections, forge new alliances, and begin the slow but necessary process of imagining a post-imperial global health. The self-inflicted isolation of the U.S. from global health governance creates space to rethink hierarchies and reimagine leadership in urgently concrete ways. No longer just an ideal, dismantling structures of dependency and reshaping the notion of the “global” has become an unavoidable necessity in light of this crisis.

What can we learn from history?

Past critical junctures in the history of Global Health provide a ground to consider the current opportunity and its risks. During the effervescent years of the Cold War (1960s and 1970s), the United Nations (UN) and the WHO faced significant efforts to establish a new order in global politics and health affairs, linked to the success of the decolonisation movements and the international financial crisis of the oil-producing industry. Newly independent nations rallied around the so-called Non-Alignment Movement (NAM), founded in 1961 in Belgrade (former Yugoslavia) by socialist leaders, seeking to challenge the hegemony of a dichotomous world by establishing a third way outside predetermined modernist models. For a while, the project worked. The NAM and its sister organisation G77, successfully drafted and pushed for the so-called New International Economic Order (NIEO) that made its way through all bodies of the UN. Though the priority focused on new trade agreements and interstate justice, the movement reformed the UN to grant voting rights of equal weight to all member states independent of their financial contribution – effectively giving political power to historically marginalised nations. At the WHO, the reforms and inclusion of new actors enabled a fundamental push for expanding and strengthening community-based initiatives foundational for establishing the Primary Healthcare approach at the Alma-Ata Conference in 1978.

As much as this brief institutional history might yield hope in a new order, we’d be wise to pay attention to the outcomes of these attempts and how these have shaped global health governance as we have it today. Mainly, merely years after the worldwide promotion of the PHC approach and derived from the rise of neoliberalism, efforts towards inclusion and balanced forces faulted back to the status quo around the Global North. The comprehensiveness of initiatives was reduced to vertical and technocratic measures, scalable for measurement and success in the evolving global health arena. Meanwhile, the emergence and expansion of new private actors in health philanthropy and humanitarianism helped consolidate a global hierarchy of governance that now rallies around corporate logic and power imbalances – with capitalist governments, like the US, at the forefront. Undoubtedly, much of the imagination and innovation of the prosperous 1960s no longer feature prominently in contemporary health debates.

Visualising structural change will always be difficult, but a new order is possible, and we can collectively labour in this direction. The potential changes, though, are feeble without a structural basis that sustains the transformation, and history may advise us to remain attentive to recurring back to a status quo because it is “safe.” The direction is uncertain and, to a significant extent, outside our control. Today, we see a fracture of the current order, a momentary suspension of normality. It is an opportunity to articulate our aspirations and create new designs. We face a miniature space upon which alternative horizons can be imagined.

Toward a Truly Global Vision

What could a truly global global health system look like? The decolonising global health movement and calls for equity in this field suggest some answers:

First, it would centre the intellectual and practical contributions developed outside of the traditional centres of power. Regional initiatives such as the African Union’s Centres for Disease Control and Prevention (Africa CDC) and collaborative mechanisms in Latin America such as the Latin American Social Medicine Association (ALAMES in Spanish) have already demonstrated the capacity for leadership and innovation that are instrumental in future orders. Strengthening and expanding these regional efforts can provide a foundation for a more decentralised global health architecture. Second, funding structures must be diversified. The reliance on a few major donors creates vulnerabilities that undermine the long-term sustainability of global health initiatives, and skews research and practice agendas away from transformational change necessary to achieve health equity and justice globally. Expanding the pool of contributors—both geographically and across sectors—would reduce dependency and increase resilience. Finally, global health must move beyond its contemporary reliance on nation-states and corporate actors to incorporate the voices and expertise of grassroots organisations and those most affected by global health policies. A more inclusive and participatory governance model is essential for ensuring equity and fairness.

Embracing the Moment

The U.S. withdrawal from the WHO and the potential collapse of USAID has revealed just how dependent the field has become on a single actor. More precisely, they reveal how the global health system has been designed around this dependency. This is a challenging moment, but it is also an inflection point. The temptation to restore the status quo and breathe a sigh of relief is strong—to see the U.S. back at the centre, pumping resources to keep existing structures afloat. Others might wish to replace U.S. leadership with an equally centralised arrangement, but that would simply continue the status quo, patching over systemic gaps rather than addressing the deeper inequities that have long defined global health. Such relief would be understandable, but ultimately shortsighted. Instead, we must use this moment to confront the deeper structural inequalities that have shaped global health and work toward meaningful transformation

What we are proposing—a decisive departure from control and tutelage of the USA in Global Health—should have happened long ago. It should have happened after Alma Ata. It should have happened after the failures of the global response to COVID-19, partly attributable to vaccine nationalism. It should have happened when the U.S. vetoed UN resolutions that would have allowed humanitarian relief in Gaza, instead endorsing the genocide of the Palestinian people and the destruction of their healthcare infrastructure at the hands of Israel. It didn’t. And for some, this is still not the moment—not without a reliable alternative in place. But that alternative must be imagined and built—one that does not hinge on the political whims of a handful of powerful nations.

Authors’ note: We thank Dr Seye Abimbola for useful early commentary on this piece.

About the authors:

Cristian Montenegro is a Senior Lecturer in the Department of Global Health & Social Medicine at King’s College London and an Affiliate Researcher at the Programa de Salud Mental Global, Universidad Andrés Bello, Chile. Drawing from sociology and with a focus on South America, his work critically examines how values shift in mental health policy across local and international scales, exploring how different groups—including service users, policymakers, caregivers, and service providers—engage with and reinterpret core normative categories such as human rights, community, participation, and democracy. He currently leads the Transitions project (The Ethics and Politics of Psychiatric Deinstitutionalization in South America) in collaboration with the Escuela de Salud Pública Salvador Allende in Chile and the Instituto de Medicina Social at the Universidade do Estado do Rio de Janeiro.

Sebastian Fonseca is an international physician with an MA in Philosophy and Politics of Health (UCL, 2015) and a PhD in Global Health and Social Medicine (KCL, 2020). He currently works as a postdoctoral research fellow at the Wellcome Trust-funded project “Connecting 3 Worlds: Socialism, Medicine and Global Health after WW2” (University of Exeter) and as a visiting lecturer to the Department of Global Health at the University of Maastricht (NL). His work explores cases of health socialism in Latin America and global histories of community health, intersecting perspectives from medical anthropology, history of medicine and science and technology studies. Fonseca is completing his first manuscript titled “Rabia Digna: Latin American Social Medicine after World War II,” delving into the development of social medicine in the region in the second half of the twentieth century.

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