LONDON — The abrupt withdrawal of U.S. global health funding that many disease control programs and developing countries have long relied on presages a leaner future for the sector, says the head of one of the world’s largest charitable foundations.
Charities and other governments will be unable to fill all the gaps left by the Trump administration’s decision to slash aid spending, John-Arne Røttingen, CEO of the Wellcome Trust, told STAT in an interview.
The trust is the world’s fourth-largest charitable foundation, with an endowment of about 37.6 billion pounds, or nearly $49 billion. It funds health research with a particular emphasis on infectious diseases, climate and health, and mental health.
Røttingen, who has been at Wellcome’s helm since the start of 2024, said the World Health Organization too is going to have to figure out how to function with fewer resources, given the planned U.S. withdrawal from the international health agency. The United States has in recent years provided about 18% of the WHO’s overall budget, through a combination of assessed contributions — effectively membership dues — and voluntary donations earmarked for programs of specific interest to the country.
More broadly, the United States spends about $12 billion annually on global health, less than 0.1% of the federal budget.
Though many disease control efforts are reeling because of the unexpected U.S. retreat from aid funding, Rottingen suggested it would be prudent to take stock and figure out how best to proceed with what will inevitably be fewer donor dollars before moving to try to fill the gaps left by the U.S. cuts.
This transcript has been edited for length and clarity.
What does having the United States withdraw from international aid in such an abrupt fashion do to the community of organizations that are trying to promote global health? I don’t know how people are thinking about whether different organizations can fill the voids, but I would imagine something like the Wellcome Trust is not a ship that you can turn around on short notice. Its funding would be committed already to other projects.
The U.S. is and has been and will continue to be, I’m sure, one of the key players in the global system, from R&D innovation to also making sure that access [to medicines] is delivered around the world. It’s the world leader in health research funding.
Among the countries in the development space, the U.S. has prioritized health the highest. It’s delivered a lot of good for people on the ground, but also in reducing the incidence and transmission of infections and controlling epidemics and pandemics.
The U.S. is a large country with a lot of institutions, a lot of people, commitment, and that will not go away.
You’re confident of that?
In the long run. We are 50 days into a new presidency, and I think there are many drivers for what we see there. They are not necessarily fully thought through. And I think they’re even saying themselves that “We may fail and we will correct.” And we’ve already seen some of the firings [of government workers] resulting in rehirings.
Wellcome is an international global philanthropy. We will always need and want to work with governments that are democratically elected. But I think we also need to see how this will land and then understand where we can play a role.
We don’t know how large that gap will be after, hopefully, a new steady state [emerges]. But the scale of the U.S. role — in both money, but also its technical and institutional capacity — means that no one can fill that gap. The philanthropic foundations will definitely not be able to fill the gaps.
We also see in the current geopolitical climate and the concerns around security and the need for increased defense spending in particular in the other major aid donor countries, there’s no likelihood that governments will fill that gap either.
So overall, I believe that the system then also really needs to look for how we can deliver better and more impactful results with the resources we have. How can we mobilize new resources? But those resources also need to come from domestic resources and capabilities in [aid-recipient] countries that are the most affected. The toughest [aspect] is that this is happening so quickly. And I think we risk losing some opportunities if we respond too quickly.
I think we need to have a bit longer time horizon when it comes to what can be done and where should philanthropy, for instance, play a role.
It sounds like what you’re saying is that the answer to this abrupt cancellation of U.S. aid funding is not an abrupt reassignment of those responsibilities. Is that correct?
Yes, because I’m very confident that we are not able to fill the gaps as is. So it means that if we don’t try to do something about the delivery and the way the system is working, then there will still be huge gaps after filling the gaps that are able to be filled, and we will not really maintain the goals of supporting people and alleviating ill health and continuing treatment.
Of course, that’s easy to say from a bird’s eye perspective. It’s much harder if you are on the ground in Malawi and you see that people no longer have jobs. Health care workers need to sustain families and they need to go to try to find other work instead of actually doing what they are trained for.
In a way I think we also actually demonstrated that the global health ecosystem of aid is vulnerable, when a decision from a funder one day can lead to people not being paid a couple of days later on the ground. It means that we have a very vertical integrated delivery system. I think we need to think more through how to be more robust, resilient, and probably more integrated really on the ground.
We have tended to have vertical programs, disease by disease and by different implementers, so it means it’s harder to see [possible] efficiencies.
Has there been outreach among organizations like yours — with the Gates Foundation, with other of the major funders — to try to figure out how to function in this new world?
Oh, definitely. So there are a lot of informal meetings and conversations to try to collectively make sense of where we are, and learn from each other. We’re seeing the impact on the ground in the institutions that we see as our major partners in Africa and Asia.
A lot of the clinical or public health-oriented research is very much dependent on a health care delivery aid-funded program and it’s really connected. So if there are cuts in the aid-funded program, it also impacts the research, and somewhat vice versa as well.
We have institutions that we fund with core support that are definitely dependent on research funding from the United States government.
But on the research side, I think it’s too early to see what kind of impact and where the priorities will be. I guess the new NIH director is still not confirmed….
The Senate Health Committee voted to endorse Jay Bhattacharya’s nomination on Thursday, but the full Senate vote is still to come.
So of course we wait to see the new priorities and how NIH will operate in this international landscape.
Is this going to lead to more need for individual countries to fend for themselves? Are we looking at a world where developing countries just have to face the reality that there will be substantially less aid coming?
I think that’s the realistic scenario. That’s not just driven by the U.S. changes, it’s also driven by changes in other governments, including here in the U.K. As you know, the U.K. government, because of the security situation, has also announced a reduction in official development aid from 0.5% to 0.3% of GDP. Other European governments have already announced that.
So my expectation is that the health aid envelope overall will definitely be reduced substantially in the coming years. That’s why I say we need to double down on effectiveness and efficiency in the system and also doubling down on trying to maximize the use of domestic resources, also for health, but of course, differentiating what countries can do.
The poorest countries are not able to deliver basic health services, even if they use a substantial proportion of their GDPs. So there needs to be support in the poorest countries. But maybe we need to concentrate the aid support to the poorest countries as one way of making sure that we deliver where there’s the most need.
When you talk about the U.S. involvement internationally, you aren’t talking in the past tense. It sounds like you feel they will remain in the field. What gives you that sense of confidence? The vibe that President Trump gives off is very much ‘We’re done paying for the rest of the world. The bank is closed.’
So I think we need to be clear, because the health ecosystem is large, from R&D to aid delivery in a way. On the life sciences ecosystem and industry side, as you know, the U.S. is such an important actor. Huge biotech industry. The biggest pharmaceutical companies. The major pharmaceutical market. And it means that the U.S. has been driving innovation, benefits to patients, a lot of improvements, new technologies.
That’s a benefit to the U.S. population. It’s a benefit to the U.S. economy. Life science industries are a strong part of the U.S. economy. I’m very sure that the Trump administration would want to still maintain that leadership role in life sciences, and now also maybe life sciences linked to technology and AI and new opportunities.
On the aid side, I definitely understand that there is more focus on protecting American people and benefits to America. But the space where that is the most explicit is indeed infectious diseases.
And I believe now just a few years after the pandemic, it will be very high on the mind of any politician that we need to control the spread of infectious disease and make sure to protect our own populations. And the only way to protect our own populations is to make sure that the world is better prepared. And I would expect that health security and biosecurity would be a priority of a Republican administration in the U.S.
When I think about the pandemic and what came out of it, there was the extraordinary speed at which vaccines were available and put into use….
That was a victory of science. This would never have happened without long-term investment in basic science and then a very proactive investment in applied science.
It was amazing. And it could happen again, faster, if the next pandemic is a flu pandemic. But I’m worried about people’s willingness to be vaccinated and the distrust that has arisen, at least in the United States. There are a lot of people who want nothing to do with mRNA vaccines. Is that a concern to you?
We are definitely concerned about the long-term trends in trust in science.
We have done a couple of global monitoring surveys on understanding the attitudes to science and scientifically driven solutions and evidence-based policy around the world. We will continue doing that. I think there’s a lot of research indicating that people trust science when they understand that science is about the challenges and the problems they are grappling with. So I believe there’s also a responsibility for science to engage with citizens, engage with communities, demonstrate that we are providing value, that we are listening to the voices of people when setting priorities and understanding which problems we want to tackle. We’re not just saying, “Please trust us.” You actually need to engage and tackle the most important problems people have. And I think we’ve lost something in that communication.
Unfortunately, science also became partly politicized during the pandemic, more in some countries than others. Definitely a combination of vaccines, but also the use of public health measures. I think you can always debate and discuss what were the right decisions. I think definitely the early introduction of vaccines. And actually, if we had been even faster, we would have saved millions more lives internationally.
Let’s talk about the WHO. When President Trump signed the executive order announcing the U.S. withdrawal, some people hoped it was a bargaining tactic, that he was looking to force other countries to pay more. The joint resolution of Congress that let the United States join WHO requires the country to pay outstanding bills before leaving, but last year’s dues should have been paid in January and they weren’t. At this point it seems quite possible that the U.S., the agency’s biggest funder, is out and it’s not going to make good on what it owes. How does WHO function without 18% of its budget?
So first, I think the world should have an expectation that any international agreement is adhered to.
Bills should be paid?
Bills should be paid. Countries are also free to leave organizations, but they should, of course, pay their dues until they have left. I think that’s the rule of law, so it’s my expectation that will happen.
I won’t speculate on whether this was a negotiation tactic or not, but I think we just need to take it at face value. The U.S. has indicated they have left WHO. So WHO would need to plan for a smaller budget and, and really make sure to deliver on that. But then at the same time I think it would be really important to engage proactively with the United States to better understand the United States’ expectations of the organization. What has been working? What has not been working? What are the potential reforms that the U.S. government has been looking for and potentially have not been happening? So really engage in understanding the concerns.
I think WHO would need to plan for and really work hard on downsizing and reprioritizing, making sure that they deliver on the core functions of WHO. Because it’s such an important organization.
Wellcome is really committed to WHO. We pledged $50 million in the funding round [in October] in Berlin. This is the first time the Wellcome Trust actually pledged in a context like this. Of course, our role is to support the scientific capabilities and evidence-based policies. The norms, the guidelines, making sure that science is driving the recommendations and the policies of WHO.
Are there things that you can think of that WHO is doing that it doesn’t need to be doing?
I would rather say that given that there will be a smaller budget, I think WHO would need to prioritize. They need to look at whether there is duplication across divisions, across headquarters and regional offices. Can we get more out of the resources by devolving some responsibilities to the regions? Reducing costs by operating in other environments than Geneva only?
Regional directors together with the director general should really double down on seeing how they can deliver better together by using the expertise across regions and headquarters to provide the normative functions of WHO.
I know I need to let you go. Is there something I haven’t asked you that you wanted to talk about?
We are co-investing with the Gates Foundation on the TB vaccine, M72. We are very hopeful that that will be demonstrated to be effective — sufficiently effective. Of course, the [Phase 3] data will not be out until maybe early 2028. But if that is the case, that would be another example of how important new technologies and science-based solutions are for controlling the most deadly infectious disease globally currently.
I hope we then also have a global health ecosystem that will be able to scale up and deliver such an important vaccine.
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