With 80,000 employees and a budget of $1.8 trillion, the U.S. Department of Health and Human Services (HHS) is a federal behemoth focused on improving the health and well-being of all Americans.
However, the department is also a heavyweight internationally, spending $1.6 billion on global health in 2024, said Jennifer Cates, director of the Global Health and HIV Policy Program at KFF. (Last week, the Trump administration directed HHS to cease all public communications, and the department did not respond to NPR's request for comment about this estimate and its global health portfolio.)
This global work ranges from training public health officials in other countries to coordinating vaccination efforts for refugees. "We're a big player in global health, and we have great partnerships with other countries," says Donna Shalala, who was HHS secretary under Bill Clinton from 1993 to 2001.
So it’s clear that whoever leads this federal agency under Donald Trump will have a huge impact on global health. The current nominee is Robert F. Kennedy Jr., who, as NPR reported, “has an extensive history of making false and misleading statements on vaccines and infectious diseases.” His confirmation hearing is scheduled to begin on January 29.
To get a sense of what international issues the new secretary will dominate, NPR interviewed Shalala and another former HHS secretary, Alex Azar, who previously served in the Trump administration, as well as global health analysts and researchers. Here are the key ways HHS shapes global health.
Family Planning and Reproductive Health
The U.S. government is the largest donor to family planning and reproductive health worldwide, with about $600 million in funding each year. The State Department is deeply involved in these efforts with two agencies under HHS authority: the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC). For example, NIH has funded relevant research, and CDC provides technical assistance, to help countries identify, report, and reduce maternal deaths. Both of these agencies — and their budgets — are under HHS oversight.
For example, from 2013 to 2018, CDC co-led the Saving Mothers, Giving Life Initiative to reduce maternal mortality in Zambia and Uganda — a public-private partnership to eliminate delays in getting medical care to pregnant women. CDC helped coordinate the initiative, funded partners to implement it, and assigned experts to work with local government officials to evaluate its success. The CDC determined that the program reduced maternal mortality by 41% in Zambia and 44% in Uganda.
Global Vaccination Efforts
Shalala says that, worldwide, HHS has been “at the forefront” of vaccination campaigns, from helping to eradicate smallpox in the late 1960s and 1970s to tackling childhood diseases in every country on Earth. Working with international organizations, they also “helped negotiate treaties and stopgap measures where there were wars so we could vaccinate. We got most of the world serious about vaccinating children.”
Vaccines are also a critical element in addressing the global refugee crisis. In President Trump’s first administration, HHS led the Western Hemisphere’s response to measles and diphtheria outbreaks in Latin America, says Alex Azar, who was HHS secretary from 2018 to 2021.
One emerging issue during his tenure was the economic strain in Venezuela, which has led millions of people to flee to other countries, where they have overwhelmed the health care systems of neighboring countries.
Azar convened Western Hemisphere health ministers to discuss the issue. Among the solutions: providing medical assistance, sending a U.S. Navy hospital ship to the region, and helping the Pan American Health Organization rebuild health care systems in countries accepting refugees.
Azar and his fellow health ministers also created a vaccine card for migrants.
“Refugees will come out of Venezuela, and they will need to get vaccinated because they have no proof or record of vaccination,” Azar says. “You go to Colombia, get vaccinated, but then you migrate to Panama — and if you don’t have reciprocal and valid proof of vaccination, you have to get vaccinated again.” The idea of a mutually recognized vaccination card was an easy way to avoid duplicative efforts and prevent infectious diseases.
“It’s better to solve the problem where it’s first identified than to wait until migration,” Azar says. “We have a vested interest in trying to make sure these individuals are healthy.”
In more general efforts to help vaccination efforts, HHS provides funding and research support — both in the U.S. and abroad — to get vaccines from laboratories to real-world use. One example, Azar says, is how the Food and Drug Administration (FDA), another HHS agency, oversees clinical trials and vaccine approvals.
Pandemic Preparedness and Response
Another area of HHS focus is pandemic prevention, from identifying new threats to scaling up a broader response.
For example, Shalala led HHS at the height of the HIV/AIDS epidemic. Her efforts included increasing NIH funding to find and test countermeasures to stop the outbreak, which ultimately led to “millions of dollars in treatment in other countries,” she says. “There had to be an international response at every level, at the treatment level, at the research level, and at the clinical trial level. Our scientists are internationalists; they don’t lag behind.”
In the mid-1990s, the U.S. It funded 40-50% of HIV programs in low-resource countries.
In addition, many of the scientists on the front lines of the AIDS response were trained by the U.S. “The major contribution by CDC is really training an entire generation of public health officials,” Shalala says. These local officials are complemented by CDC members who are based in more than 50 country offices, often working to detect and respond to new epidemics, and also providing detailed information to multilateral organizations like the World Health Organization.
“Diseases don’t know what borders they’re crossing, and we need to be in strategic locations with our expertise to collaborate with the rest of the world,” Shalala says.
The order also includes building and strengthening public health laboratories to monitor disease trends and guide control efforts.
While the framework for fighting a disease isn’t yet in place, HHS can jump in to build it when an outbreak occurs. For example, starting in 2018, a major Ebola outbreak occurred in the eastern Democratic Republic of Congo, a volatile region with a decades-long history of conflict and more than 120 militias and armed groups operating in the region. “You literally have no public health infrastructure, you have a devastatingly poor country, you have really limited civil service and government that is functioning in the area,” Azar says. “Cases just kept spreading and spreading.”
HHS helped coordinate the response, expanding access to rapid diagnostic tests, helping to run clinical trials of vaccines and therapeutics, and designing Ebola treatment centers. Azar traveled to the region, meeting with the country’s president and leaders in neighboring Rwanda and Uganda to coordinate the response.
A key challenge was that the local population viewed Ebola treatment centers as places where patients would die. So HHS staff — and Azar himself — met with faith, community, and tribal leaders to show them that, with new antiviral drugs, people could get into these centers and recover. With that kind of support, the Ebola outbreak ended in July 2020. “For another reason, very few people paid attention to it,” Azar says. “It’s one of the great public health achievements of our time.”
Global Health Diplomacy
HHS also has a track record of working with other countries to protect global health. “After 9/11, there was a real concern about anthrax attacks and bioterrorism and chemical agents, about how we could bring the world together to coordinate and mitigate these threats,” Azar says.
As a result, President Bush stepped up efforts in global health diplomacy, such as launching the U.S. President’s Emergency Plan for AIDS Relief. Since its inception in 2003, the program has invested more than $110 billion in the global HIV/AIDS response and is credited with saving more than 25 million lives. The State Department is the primary branch of the U.S. government working on both programs, but HHS contributes scientific expertise and support. (Last week, as part of an executive order affecting foreign assistance, PEPFAR funding was suspended for 90 days.)
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