The End of Global Public Health?
How public health reached its current crossroads—as I understand it!
Before World War II, public health efforts in the colonies—what we now refer to as the Global South—were predominantly guided by colonial interests and termed “tropical medicine.”1 Work by figures such as Ross and Koch on malaria, tuberculosis, cholera, and plague was aimed at laboratory and clinical methods, particularly in bacteriology, parasitology, and entomology. It was primarily aimed at reducing the spread of diseases to protect colonial armies and administrative officers, with local populations playing a crucial role in achieving these goals. In contrast, public health improvements in the Global North were largely a byproduct of economic growth, sustained by gradual investments in public goods like waterworks and sewage systems that effectively and sustainably controlled disease spread.2
Countries across the Global South gained independence after World War II. In the same decade, multilateral organizations such as the United Nations and the World Health Organization (WHO) were established. In 1948, as part of its constitution, the WHO introduced a broader definition of health—"a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." This marked a shift from a disease-focused approach to a theoretically more comprehensive perspective.
Even before the establishment of WHO and its mission, public health mission had already begun expanding in the early 20th century long before World War II. In the 1920s, U.S. public health thought leaders like Winslow articulated a broader vision: "preventing disease, prolonging life, and promoting physical health and efficiency."3 Despite this conceptual evolution in the Global North, funding patterns for public health in the Global South remained largely unchanged. Countries in the Global South received ‘aid’ to implement programs aimed at purchasing medicines for a particular disease, reducing the spread of another disease, and training doctors or task-shifting capacity through training for a third disease. However, there was very little investment made either by Global South politicians and administrators or by Global North funders in building and maintaining drainage systems and ensuring the maintenance of clean air.
During the Cold War, we witnessed how ideological differences influenced public health approaches. Communist states prioritized primary healthcare systems, while non-communist states, like the U.S., favoured efficient vertical, disease-specific programs. (It is important to note here that neither of the two approaches focused on public goods such as drainage systems, clean water, etc., which were responsible for improvements in public health outcomes in the Global North.) Over time, public health funding expanded to include influential actors such as the World Bank and philanthropic organizations — first the Rockefeller Foundation and later the Bill & Melinda Gates Foundation. These organizations reinforced a programmatic, theory-of-change approach to public health, focusing on measurable outcomes and evidence-based interventions for specific diseases. In 1980, against the backdrop of the Cold War, ‘the United States and the Soviet Union worked in rare solidarity’; with heat-stable, freeze-dried smallpox vaccines, and with strategies like ring vaccination, smallpox was globally eradicated.4
In 1980, a very popular film (Why Did Mrs. X Die?)5 was released; it detailed the complex factors beyond primary clinic care and tertiary hospitals that play a role in maternal mortality. This video has since been translated into multiple languages across the world. This short film is an early summary of what we popularly call Social Determinants of Health (SDoH) — the non-medical factors that influence health outcomes. While health inequity and SDoH have been fairly regularly discussed in international public health discourse since the 1980s, especially in maternal mortality, HIV, and TB, I believe that the early 2010s marked a shift when SDoH gained mainstream attention in the United States. It is hypothesized that McCarthyism, the discovery of DNA in the 1950s, and the subsequent Reagan Era led to a hyper-focus on biological etiology and the further development of epidemiologic theory based primarily on biology, attributing what could not be explained by biology to individual agency.6 In the following decade, research into quantifying how different SDoH led to inequities in health outcomes helped call for a political agenda to bring about systemic change and ensure health equity for all. While this helped raise awareness of structural health inequities, it also led to deeply polarized, U.S.-centric ideological debates regarding the extent of the government's role in addressing these health inequities.
The polarization of U.S. political discourse has affected how SDoH is interpreted, leading to simplistic narratives that either dismiss its relevance altogether or overstate its role as the singular root cause of differences in health outcomes. This hyper-polarized framing in political dialogue has undermined constructive discussions on addressing non-medical factors that influence health outcomes.
In late 2024, with Donald Trump’s re-election, many anticipated shifts in the U.S. public health structure. It was understood early on that research on health inequities was going to be disincentivized and potentially even penalized. Similar to the first Trump term, it was anticipated that USAID’s public health priorities would be realigned with conservative priorities, potentially affecting funding for projects related to abortion and LGBTQ+ health.
However, what has unfolded in the early months of Trump’s second term is far more catastrophic than anticipated. Liberal and democratic values, which form the backbone of public health research and programmatic implementation, are being actively undermined.
The overnight demolition of USAID has upended global health funding, and the CDC has removed some publicly available datasets and webpages. Meanwhile, the National Institutes of Health (NIH) is undergoing a fundamental restructuring, and NIH-related research funding for topics —related to DEI like SDoH— is being rescinded through stop-work orders, leading to widespread layoffs and tectonic shifts in research funding priorities. Crusaders of freedom of speech now have a list of banned words!
We are seeing references to the end of The End of History. We are seeing direct calls for the end of globalization, the end of consensus around humanitarian aid, and witnessing indirect calls for concrete action toward ending non-partisan health research and public health decision-making. Soon, we will witness the loss of mainstream public health guidance, expertise, human resources to mentor and guide younger talent, and exponential reduction in global disease surveillance. One could argue that some of these shifts were already happening gradually in the post-COVID timeline. Public health advice/information sources were decentralized as COVID progressed, and the expertise was polarized. One side of the debate couldn’t civilly agree or disagree with the other without name-calling and virtue-signalling.
However, this polarization was driven by a vocal minority, while the silent majority continued to trust the mainstream public health advice. Now, these COVID-19 era microcurrents are mainstream and are shaping policies that will not only impacts Americans but also those all across the world who are supported by U.S. public health expertise, datasets, institutions, and grants.
A career in public health
I chose to pursue public health in 2015, envisioning a career in a world shaped by scientific consensus and global collaboration. I assumed scientific processes and institutions to be some degree permanent. I thought that the arc of progress was liberal, rooted in scientific evidence, bright, and future-forward! That world and those assumptions feel unrecognizable today.
Back in 2015, I was particularly curious about vaccine hesitancy. In the Global North, discussions had restarted revolving around unfounded and repeatedly disproven concerns linking vaccines to autism, particularly regarding the MMR vaccine. These debates were distinct from vaccine hesitancy in the Global South, where skepticism was historically linked to religious and cultural beliefs with polio vaccination campaigns etc. I wanted to understand whether these Global North narratives were also influencing urban populations in India, where digital access and social media interactions were ever-increasing. This became my first public health research project, I applied for an ICMR Short-term studentship grant, secured it, and as a second-year MBBS student started collecting the data.
Now, in 2025, Robert F. Kennedy Jr., a leading figure in the anti-vaccine movement, is the U.S. Secretary of Health and Human Services, effectively overseeing the country’s public health strategy. Long-serving senior officials at NIH like Francis Collins and Peter Marks at FDA have resigned, forced to resign or have been laid off.7 This signals a dramatic shift, not just for U.S. public health policy but for global public health, given the U.S.’s outsized influence in the global discourse.
I feel a deep sense of loss. Not only for my own long-term career prospects but for my colleagues, mentors, and institutions that have shaped public health for decades. Very few countries have developed a research ecosystem where a career in public health is both sustainable over the long term and ethically rewarding, rather than just financially viable. My second fear is the loss of institutional expertise. The current dismantling of public health agencies is not just about budgets—it’s about people. The career scientists, epidemiologists, monitoring and evaluation specialists, and policy experts who are being laid off represent decades of experience and mentorship. Even if a future administration rebuilds these institutions, knowledge gaps will persist. Expertise cannot be easily replaced, and artificial intelligence cannot fill the gap left by seasoned professionals who grasp the nuances of generating public health evidence and making decisions at the hyper-local level. Lots of early career federal and NIH, USAID supported jobs have been canceled, making it difficult for early-career public health researchers to find meaningful jobs, continue learning through practice, and progress through mentorship and guidance.
American health discourse is increasingly hyper-individualistic, distrustful of formal health guidance, and skeptical of public health interventions like vaccines. Many now question whether these measures truly protect population health and reject the idea that individual liberties can be reasonably limited through interventions like vaccine mandates.8 While many still recognize the value of public health, skepticism has deepened—initially among the political right during COVID-19 and now, with the dismantling of key institutions,9,10 it will be difficult to trust formal guidance across all ideologies.
Fragile institutions and the need for open dialogues
Beyond sadness, I feel fear!
First from the erosion of non-partisan, science-based institutions. Historically, organizations like NIH, CDC, and USAID operated with a level of independence, ensuring that public health decisions were informed by data rather than ideology. But with large-scale layoffs, funding cuts, and even bans on use of certain scientific terminology, the integrity of public health research is under serious threat.11
I grew up in a world where reliable public health information was easily accessible. If I had a question, I could Google it and find fact sheets from CDC or WHO. If I needed datasets, I could access multiple datasets and dashboards, from anywhere across the world, through various NIH, USAID-funded research projects, or CDC websites. These resources were indispensable during COVID-19, for example, CDC’s Morbidity and Mortality Weekly Reports and various COVID-19 trackers were critical sources of real-time information. Now, these very precious resources are at risk.12 We may not feel the full impact immediately, but in the next two to five years, the consequences will become undeniable.
With the collapse of USAID, various global health projects are shutting down, leaving competent public health professionals in the Global South unemployed and creating a vacuum in technical and contextual expertise. While national governments might step in with limited funding, the challenge lies in integrating these external professionals into existing bureaucratic structures, which are often slow-moving and inefficient.
Education in foreign universities alone cannot fill this gap. Students learn not just from textbooks but through hands-on experience, mentorship, and structured training programs. Many such opportunities are now disappearing given the shortage of funding.
Secondly, public health researchers and the practitioner community have long problems with groupthink and rigid adherence to certain paradigms. It was most evident during COVID-19 when the expert discourse shifted very actively to Twitter (public town square instead of being limited to conferences etc). Dissenting perspectives were quickly condemned through virtue signalling, name-calling. This has led to slower policies, missed opportunities to communicate evidence for change in policies, and a lack of collective responsibility for ineffective interventions.13 Early career researchers were often required to navigate this thin boundary, learning how to engage in discourse without crossing unwritten lines.
While there have been positive efforts to make the field more interdisciplinary, pluralism of thought, breadth of discourse, and space for debate is limited for all. Now more than ever, public health institutions must reckon with their COVID-19 related advocacy, simultaneously speak out against active and upcoming misinformation about public health research and interventions. Public health institutions must embrace the liberal and democratic value of free speech, remain committed to fearless evidence generation and scientific inquiry, and pursue evidence-informed, non-polarized public health advocacy.
It is imperative that public health researchers do not feel fear—while a few hesitated to express their views before January 2025, an unimaginably larger number now feel silenced in its wake. NIH grants that were already awarded and work in progress, those that focused on advancing disease transmission and prevention knowledge in vulnerable populations like MSM, transgender people, adolescent girls, and women, have been abruptly cancelled.14 International students and international researchers on work visas cannot safely participate in public health advocacy or any political discussion related to health. How does one develop healthy scientific enquiry and think out loud in these times?
Conclusion
Public health has always evolved in response to political and social changes, but the shifts occurring today are unprecedented. The world I entered as a student of public health in 2015 no longer exists in 2025.
We are witnessing the erosion of public health infrastructure driven by ideological polarization, funding cuts, stop research orders, and the systemic dismantling of institutions. The loss of institutional capacity in non-partisan, science-based organizations like NIH, CDC, and USAID is imminent, and it threatens the integrity of public health research. The politics of the current moment are fundamentally opposed to globalization. Public Health depends on multilateralism, global collaboration, exchange of knowledge, resources, and innovative solutions across borders.
The consequences will unfold over decades, early signs are already visible. For now, I am naming my big feelings and seeking to understand, in greater detail, how these global scientific institutions were built, slowly and steadily, over time.
Notes and References
1. Power HJ. Tropical Medicine in the Twentieth Century: A History of The Liverpool School of Tropical Medicine 1898-1990. Routledge; 2012. doi:10.4324/9780203039175
2. Gallardo-Albarrán D. The global sanitary revolution in historical perspective - Gallardo‐Albarrán - 2025 - Journal of Economic Surveys - Wiley Online Library. Accessed March 28, 2025. https://onlinelibrary.wiley.com/doi/10.1111/joes.12607
3. Kemper S. Public health giant: Remembering the man who launched public health at Yale | Yale News. June 2, 2015. Accessed March 28, 2025. https://news.yale.edu/2015/06/02/public-health-giant-c-ea-winslow-who-launched-public-health-yale-century-ago-still-influe
4. History of smallpox vaccination. Accessed March 28, 2025. https://www.who.int/news-room/spotlight/history-of-vaccination/history-of-smallpox-vaccination
5. Why Did Mrs X Die, Retold.; 2012. Accessed March 28, 2025. https://www.youtube.com/watch?v=gS7fCvCIe1k
6. Krieger N. Epidemiology and the web of causation: Has anyone seen the spider? Soc Sci Med. 1994;39(7):887-903. doi:10.1016/0277-9536(94)90202-X
7. Kaiser. Former NIH Director Francis Collins retires suddenly, makes plea to protect agency staff. Accessed March 28, 2025. https://www.science.org/content/article/former-nih-director-francis-collins-retires-suddenly-makes-plea-protect-agency-staff
8. You. Here’s the visual proof of why vaccines do more good than harm. Accessed March 28, 2025. https://www.science.org/content/article/here-s-visual-proof-why-vaccines-do-more-good-harm
9. Sun LH, Nirappil F. Vaccine skeptic hired to head federal study of immunizations and autism. The Washington Post. https://www.washingtonpost.com/health/2025/03/25/vaccine-skeptic-hhs-rfk-immunization-autism/. March 25, 2025. Accessed March 28, 2025.
10. RFK Jr. Turns to a Discredited Vaccine Researcher for Autism Study - The New York Times. Accessed March 28, 2025. https://www.nytimes.com/2025/03/27/health/rfk-jr-autism-vaccines.html?smid=nytcore-android-share
11. The words putting science funding in the crosshairs of Trump’s orders - The Washington Post. Accessed March 28, 2025. https://www.washingtonpost.com/science/2025/02/04/national-science-foundation-trump-executive-orders-words/
12. Cox C, Rae M, Kates J, Wager E, Ortaliza J, Published LD. A Look at Federal Health Data Taken Offline. KFF. February 2, 2025. Accessed March 28, 2025. https://www.kff.org/policy-watch/a-look-at-federal-health-data-taken-offline/
13. Jimenez JL, Marr LC, Randall K, et al. What were the historical reasons for the resistance to recognizing airborne transmission during the COVID-19 pandemic? Indoor Air. 2022;32(8):e13070. doi:10.1111/ina.13070
14. FedInvent. HHS Published A List of Canceled Grants. FedInvent. March 26, 2025. Accessed March 28, 2025. https://fedinvent.substack.com/p/hhs-published-a-list-of-canceled