By Roger Bate at Brownstone dot org.

The US government is now committing tens of billions of dollars to global health through a growing web of bilateral agreements branded as the "America First Global Health Strategy." These deals are pitched as a way to protect Americans from infectious disease threats by strengthening surveillance and outbreak response overseas.

As of early 2026, the State Department reports that 16 bilateral global health memoranda of understanding have already been signed representing more than $11 billion in US commitments, with officials signaling that dozens more agreements are planned—a scale that makes the absence of a clearly articulated strategy increasingly hard to justify.

To understand what is happening, and why it persists even as US health care at home remains deeply dysfunctional, it helps to separate two questions that are usually blurred together: what this strategy actually is, and why the United States continues to pursue it.

Start with the "what." The America First Global Health Strategy is an operating model that emerged after the United States withdrew from the World Health Organization and needed a way to remain active internationally without WHO governance.

Instead of working primarily through multilateral institutions, the US is now signing five-year bilateral health memoranda with dozens of low- and middle-income countries, overwhelmingly in sub-Saharan Africa. These agreements bundle longstanding programs on HIV/AIDS, malaria, tuberculosis, and surveillance into large government-to-government compacts, often involving hundreds of millions—or billions—of dollars.

In substance, this is continuity more than rupture; what has changed is the structure. NGOs and multilateral intermediaries are being sidelined. Funding is routed more directly to partner governments. Co-investment and "self-reliance" are emphasized rhetorically. And the whole enterprise is framed as national self-protection: stopping outbreaks abroad before they reach American shores.

As an administrative response to WHO withdrawal, this makes sense. The United States still wants access to disease intelligence, laboratory capacity, and early warning signals. It still wants influence over procurement markets and health ministries in strategically important countries. Bilateral agreements are the simplest way to preserve those channels without returning to Geneva.

What is missing is strategy in the proper sense of the word. There is no public prioritization of threats. No explanation of which pathogens matter most to Americans. No ranking of countries by risk rather than need. No serious comparison between overseas spending and alternative investments in domestic surveillance, ports-of-entry screening, or health system resilience. Instead, almost any global health expenditure can be justified after the fact as "protecting Americans."

That brings us to the "why." Why does Washington keep expanding global health spending when US health care at home is such a mess?

The first answer is political economy. Fixing US health care means confronting powerful domestic interests: hospitals, insurers, pharmaceutical pricing, state licensing regimes, professional guilds, and entitlement politics. Every lever is contested. Every reform produces visible losers. Global health spending, by contrast, sits largely outside domestic distributional fights. It is appropriated quietly, administered bureaucratically, and justified as either humanitarian or security spending. Politically, it is easier money.

Second, US global health programs function as foreign policy tools as much as health interventions. For decades, HIV/AIDS and malaria funding has anchored diplomatic relationships, sustained US presence in fragile states, and shaped procurement and regulatory norms. That logic did not disappear when the US left the WHO. It simply moved into bilateral form. Health MOUs now serve as instruments of influence in regions where Washington does not wa...