This editorial appears in the September Issue of the American Journal of Bioethics
The COVID-19 pandemic has been called “an illustration par excellence of globalization”. Today, the world is witnessing another global health crisis. This time, the source is not a virus, but rather the current U.S. government’s “America First Global Health Strategy”. Like the pandemic, America First poses global threats to health, requiring global responses. Both are of paramount concern for bioethics, because they endanger human health and challenge human values.
America First abruptly ended funding for global health initiatives, with the largest impacts in sub-Saharan Africa (hereafter ‘Africa’). The ongoing Ebola disease outbreak in East Africa serves as a grim warning: reduced global health funding is a recipe for disaster. It critically undermines disease containment and research for diagnostics, therapeutics, and vaccines. Public health experts and health workers on the ground report that the response to the Ebola crisis has been “significantly hindered by the near absence so far of the United States, historically the leader in any major outbreak”. “Ebola can be stopped,” says Georgetown University’s Director of the Center for Global Health Policy and Politics, “and if we don’t mobilize the dollars and the public health efforts, then we are simply choosing not to stop the outbreak”.
This editorial puts forth an alternative to the America First vision for global health. It looks beyond Western approaches to engage with values prevalent among African people, values we believe are compatible with many Western values. We focus on Africa for two reasons. First, the African region is among the most heavily impacted by America First. Second, ideas from Africa, and the Global South more broadly, are frequently missing from bioethics discourse. This reflects profoundly unfair patterns of disadvantage and power that arose during colonialism and continue today. Foregrounding non-Western approaches comprise part of a larger effort to decolonize global health.
AMERICA FIRST
When Donald J. Trump took office in January 2025, the U.S. was the largest funder and implementer of global health programs, providing approximately 12 billion dollars annually, an astounding amount, yet a relatively small slice of the total U.S. federal budget (1%) (KFF 2025(a)).
On his first day in office, the President withdrew from the World Health Organization (WHO) and the Paris Climate Agreement. He abruptly froze foreign aid, issuing a ‘stop-work order’ that immediately ended payments for services and work already underway. The White House then took a wrecking ball to structures and programs around the world designed to promote health and save lives. Among these are PEPFAR (the President’s Emergency Plan for AIDS Relief), credited with saving 26 million lives and enabling 7.8 million babies to be born without HIV infection since its inception in 2003 (KFF 2025(b)); UNFPA (the United Nations (UN) Population Fund) that pays for contraceptive care for an estimated 47.6 million women and couples annually; and USAID’s (U.S. Agency for International Development’s) Neglected Tropical Disease Program to reduce the prevalence of five major neglected tropical diseases that has delivered over 1.6 billion treatments to over 743 million people. All told, “the harm will be calculated in a fatality count that will very likely rise into hundreds of thousands, at least, and to millions if the programs are not restored. It is important to reflect on the sheer scale of this American carnage”.
The shift to America First overtly and brazenly turned health and development aid into extractive tools for increasing U.S. prosperity: “our global health foreign assistance… is a strategic mechanism to further our … interests around the world…We will first and foremost make America more prosperous…We will … leverage our foreign assistance to promote American companies and American innovations abroad, including continuing to procure goods from American companies as part of our foreign assistance programs”.
A SUBSIDIARY APPROACH
The U.S. retreat from global health need not result in a Hobbesian world in which “might makes right and winners take all…a far more violent and unstable world for all of us”. It should instead prompt a reckoning. Now is the time to put forward new ways of thinking about global health. Some global health challenges require international cooperation at the highest levels of national governance. Yet, for much of global health, the focus is narrower; what is needed is a decentralized strategy, driven not only by outside funders, but also by recipient nations and communities within these nations. This approach finds expression in a principle of subsidiarity. An idea with ancient roots, subsidiarity’s guiding notion is that the burden of argument lies with those who seek to consolidate power or authority. Subsidiarity favors “a rebuttable presumption for the local” that begins from the default position that a lower level can address the underlying issue effectively. For example, subsidiarity recommends enabling individuals, families, neighborhoods, and local communities to effectively identify solutions and address problems, and only when they cannot, calls upon municipal, federal or other higher-level groups. While local communities can be corrupt and require reform, they are arguably no more prone to corruption than authority at higher levels. Moreover, the subsidiarity presumption favoring the local is rebuttable; it does not demand deference to the local under all circumstances.
Subsidiarity enacts values of non-abandonment, “when the lower-level/small community is unable to meet its goals on its own,” aid is offered; non-absorption, or honoring “the legitimate freedom of the lower-level/small community;” and coordination according to closeness to an afflicted group and the problems they suffer. A subsidiarity strategy decolonizes global health by empowering local people and communities. For example, it keeps “global level staff as technical advisers and coordinators rather than decision-makers;” ensures decision-makers have minimum “local intelligence” based on factors like years lived in a region, fluency in a local language, or longer-term collaboration; and follows “the lead of the affected communities in the assessment of their problems”. A principle of subsidiarity must be a core feature of bioethics for global health.
AFRICAN VALUES AND GLOBAL HEALTH POLICY
Following a subsidiary approach, we emphasize values in the African region, where America First has had its greatest impact. The Global Presidential Council launched by Ghanaian President John D. Mahama with other leaders from the Global South offers a promising start. “It is indeed right that the global south should take the lead, for it is in these countries that the collapse of the old world model will be felt most acutely, and it is from our innovation that the world can find new answers and solutions,” Mahama told the UN General Assembly. The so-called ‘Accra Reset’ Mahama is spearheading calls for rethinking ‘development’ to ensure nations are not passive recipients of aid but partners with local ownership, investment, and leadership. While U.S. global health aid improved health, it is frequently faulted for failing to enable countries to assume control over systems.
Africa’s Centers for Disease Control and Prevention (CDC) has put forth a strategic plan for transitioning the continent to health sovereignty, defined as “the ability of African nations to finance, produce, and govern their own health systems and countermeasures”. The proposal builds on the new public health order created in the wake of the COVID-19 pandemic, which sought to strengthen the continent’s health institutions, workforce, manufacturing, domestic financing, and partnerships amid concerns about the fragility of international cooperation when the world is collectively threatened. The WHO Africa regional office has adopted a framework to scale-up production of medicine, vaccines, and other health technologies and set targets and milestones to achieve this. Also notable is the Lusaka Agenda, a multi-stakeholder engagement that recommended strengthening primary healthcare; building sustainable, domestically financed health services and public health programs; and expanding regional manufacturing to ensure products are affordable and feasible for people in underserved regions.
Notwithstanding formidable challenges, the time seems right for transitioning to health sovereignty and inviting international partnerships that align with this vision. While calls for greater agency are not new, the geopolitical headwinds facing African and other developing countries are. Health initiatives across the Global South attest that this vision is broadly shared.
Realizing health sovereignty requires that the values underpinning global health initiatives align with values prevalent in regions where these initiatives are being implemented. A promising framework to draw on is the proposed Africa-centric research ethics framework that is “based on contextual understandings of African settings, values, virtues, cultures, and socioeconomic profiles of the region”:
In addition to the existing international research ethics principles, the Africa-centric research ethics framework will consider key attributes such as solidarity (altruism, reciprocity, and collective responsibility), friendliness (interdependence, interconnection, and respect), and social justice (equitable allocation, moral responsibility, holism, hospitality, and acceptability).
To elaborate these values, we consider prominent sub-Saharan African indigenous understandings of solidarity that incorporate key aspects of the ideas listed here.
While diverse, African philosophy frequently describes solidarity as ubuntu (humanness). Ubuntu indicates both the existential fact that human beings are interconnected and interdependent, and the ethical imperative to treat those with whom one is interconnected well. These ideas find expression in pithy sayings such as “a person is a person through other persons”, and “I am because we are, and because we are, therefore I am”. Ubuntu conveys a recognition that ‘when you do well, I do well.’ A solidaristic approach to global health commits the field to supporting all members of a group while leaving no one behind. Rather than focusing only on benefitting the most, solidarity tempers aggregative reasoning by considering the interests of each individual and group impacted by a decision. It commits global health to health equity and putting the furthest behind first. It upholds the value of nondomination by rejecting geoeconomic strategies that bully and exploit economically vulnerable groups to promote national interests. It advances dignified lives and health capability, rather than the unconstrained pursuit of extraction by powerful nations. And it can help form an ethical scaffolding for the next generation of global health values.
Solidarity often begins at the grass roots level, as a response to atrocities in our midst. Responsive solidarity involves people joining together to overcome a common foe, often during a crisis where there is rampant suffering or assaults on human dignity. In African nations, responsive solidarity might take the form of responding collectively to America First by insisting on negotiating as blocs by means of regional organizations such as the African Union, African Medicines Agency, or Africa CDC. Through collective diplomacy, African nations could strengthen their bargaining power, allowing them to define clear redlines and reject conditionalities that undermine health sovereignty.
While responsive solidarity is a potent force and has made lasting contributions, its lifespan is limited. Once an immediate health threat subsides, alliances may weaken or disband. To be sustainable, solidarity must run deeper. Deep solidarity is an ongoing response to the humanity of others. It sustains bonds of affection with others during ordinary, as well as crisis, moments. It gains a foothold early in life—”solidarity starts from the household and radiates outward to the lineage and, with some diminution of intensity, to the clan, at large. The normative meaning of this bonding, for an individual, is that she has obligations to large groups of kith and kin”. The starting point for deep solidarity can also be a relational self, “not ‘I’ and what I may owe to others, but ‘we’ and how we can flourish. This relates to a deeper understanding of our being…[as] inseparable and web-like”. Unlike responsive solidarity, which is prone to creating ‘in’ and ‘out’ groups, deep solidarity is less prone to such exclusions. While ‘familial ties radiating outward’ can generate differential commitments based on proximity, deep solidarity emphasizes common humanity, underscoring the moral equality of persons.
3. Justice and Nonmaleficence. Even if health sovereignty and solidarity are key values for African nations, when U.S. taxpayers fund global health programs, aren’t U.S. values relevant? In response, a powerful argument can be made that America First fails to uphold core tenets of American bioethics, especially justice and nonmaleficence.
U.S. policy flagrantly violates justice principles and any credible conception of a human right to health or healthcare. Diverse justice views commit to pursuing health equity, prioritizing the least well-off, and advancing dignified lives. Principles of structural justice foreground nondomination, non-exploitation, and fair power relations.
America First also contravenes nonmaleficence, a principle that “obligates us to abstain from causing harm to others;” and “above all [or first] do no harm’”. Abruptly ending global health aid left large numbers of people without access to essential health services previously guaranteed. It undermined collective mechanisms, such as the WHO, that low-resource settings rely on for essential services, further straining fragile health systems. Sudden termination of programs led to extraordinary near-term suffering and death.
CONCLUSION
America First is an ethical disaster. Its crass, ethically unjustifiable aims cannot stand. Bioethics must expand beyond the West. A principle of subsidiarity is key to that expansion.
Nancy Jecker, PhD, Vardit Ravitsky, PhD, Ruth Faden, MD, PhD, Walter Jaoko, MBChB, PhD, PGD, Jonathan Moreno, PhD, Michael Parker, PhD and Kevin Behrens, DPhil