Trump, the rise of the Global South, and a new world order for health
BMJ 2024; 387 doi: https://doi.org/10.1136/bmj.q2708 (Published 17 December 2024) Cite this as: BMJ 2024;387:q2708
At this year’s UN climate conference, COP29, countries pledged only a quarter of the $1.3tn (£1.02tn) a year needed to respond to the climate crisis, with no new commitment to cut greenhouse gas emissions. And, despite covid-19, the adoption of a strong pandemic agreement is becoming more unlikely.
Health multilateralism is in transition. The political, economic, and academic powerbase of the Global North, along with western ideological hegemony, is weakening. Reaching consensus in a new multipolar world is much harder, with strong voices from the Global South, constantly shifting alliances, and diminished trust as a result of reduced financing and constant crisis.
Into this uncertainty Donald Trump returns as US president, a gift to populist politicians and right wing movements worldwide. His campaign rhetoric, strongly critical of science and public health, has emboldened a global drive to weaken international health organisations, commitments to equitable access to healthcare, gender equality, reproductive rights, and investments in women’s health.1
But in a multipolar world, with waning US influence, focusing on Trump diverts from considering emerging powers elsewhere. 2025 will see the culmination of four consecutive presidencies of the G20—representing 19 of the world’s largest economies and the European Union and African Union—held by the Global South: Indonesia (2022), India (2023), Brazil (2024), and South Africa (2025). Brazil’s vibrant G20 agenda to fight global inequity is diametrically opposed to Trump’s policy choices.2 South Africa’s presidency will surely push in a similar direction, especially with the African Union now a G20 member.
The global health agenda is increasingly influenced by BRICS (expanded to represent Iran, Egypt, Ethiopia, and the United Arab Emirates as well as Brazil, Russia, India, China, South Africa); G7; and G20 meetings, which also include health and finance ministers’ meetings and increasingly create new health mechanisms and institutions. The World Health Organization (WHO) seeks support and cooperates to set agendas at these meetings.
Reset global multilateralism
A reset in global multilateralism is desperately needed, but no progress has been made despite repeated calls. Meanwhile, Global South leaders are forming new alliances, regional groups, and financial mechanisms and institutions—for example, China’s Belt and Road Initiative and the BRICS New Development Bank. The BRICS group is creating a vaccine research and development centre and mechanisms to regulate health products.3 The New Public Health Order for Africa from the African Union calls for a revamping of financial institutions to reduce focus on development aid.4
New tensions will emerge as large middle income countries will need to balance growing geopolitical interests with commitments made to support developing countries and to shaping a new more equitable multilateralism. After Trump threatened to leave WHO in 2020, political negotiations, financial support from the European Union, and pressure to act together during the pandemic helped WHO member states skirt an institutional crisis.
Now others need to step up. Determined health diplomacy efforts are needed to tackle stalling progress on major global health challenges. Brazil, India, and China are founding WHO members and have a historic opportunity to shape its future.
If the US withdraws from WHO, 193 countries will remain. China would be the largest single contributor of assessed contributions, balanced by the EU countries combined. Brazil holds the next BRICS presidency, and South Africa and Canada the next G20 and G7 presidencies. Might a new coalition be the deal makers?
Trump might be willing for the US to remain in WHO if it paid much less. The EU also wants a deal: more voice for its high contribution. If other large G20 countries invested more in WHO—in multilateralism for health and global health security—a deal might be struck. All contributors will seek reforms at WHO, in priority setting, transparency, accountability, and efficiency.5
In 2026 the US is due to hold both G7 and G20 presidencies, but Trump’s commitment is doubtful. Campaigning will soon begin for the election of WHO’s next director general. Several BRICS countries are eyeing the position. What happens in 2025 is critical for health multilateralism in an ever more fragmented world driven by transactional diplomacy. The G7 and G20 must push for tangible action to increase health equity and ensure human rights for health, and the World Health Assembly in May must reach a pandemic agreement, re-establish a fundamental commitment to WHO, and set a roadmap for the reforms essential to secure its future.
Footnotes
Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: none.
Further details of The BMJ policy on financial interests are here: https://www.bmj.com/about-bmj/resources-authors/forms-policies-and-checklists/declaration-competing-interests
Provenance and peer review: commissioned; not externally peer reviewed.