With 80,000 employees and a $1.8 trillion budget, 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 an international heavyweight, spending $1.6 billion on global health in 2024, according to Jennifer Kates, director of the Global Health & HIV Policy Program at KFF, a nonprofit research, polling and news organization. (Last week, the Trump Administration directed HHS to halt all public communications, and the department did not respond to NPR's request for comment about this estimate and about its global health portfolio.)
This global work ranges from training public health officers in other countries to coordinating vaccination efforts for refugees. "We are the great player in global health, and we've very much a collaborator with other countries," says Donna Shalala, who was Secretary of HHS from 1993 to 2001 under Bill Clinton.
So it is clear that whoever heads this federal agency under Donald Trump will have a tremendous impact on global health. The current nominee is Robert F. Kennedy Jr., who, as NPR reported, "has an extensive history of making inaccurate and misleading statements on vaccines and infectious diseases." His confirmation hearings are scheduled to begin on January 29.
To get a sense of the international issues that the new secretary will hold sway over, NPR interviewed Shalala and another former HHS secretary, Alex Azar, who served in the first 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 across the world with about $600 million in funding each year. The State Department along with two of the agencies under HHS authority are deeply involved in these efforts: the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC). NIH, for example, has funded relevant research, and CDC offers technical assistance, helping countries identify, report, and reduce maternal deaths. Both these agencies — and their budgets — are under HHS supervision.
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 tackle delays that pregnant women faced in obtaining medical care. The CDC helped coordinate this initiative, funded partners to run it along with local government officials and tasked specialists to evaluate its success. CDC determined that this program reduced maternal mortality by 41% in Zambia and 44% in Uganda.
Global vaccination efforts
Across the world, HHS has "played the lead" in vaccination campaigns, from helping eliminate smallpox in the late 1960s and 1970s to tackling childhood diseases in every country on earth, says Shalala. Working with international organizations, they also helped "negotiate treaties and stopgap measures where there were wars so we could get in and vaccinate. We got most of the world serious about vaccinations for children."
Vaccines are also a critical element in responding to the global refugee crisis. In President Trump's first administration, HHS led the Western Hemisphere's response to the spread of measles and diphtheria across Latin America, says Alex Azar, who was secretary of HHS from 2018 to 2021.
A looming issue during his tenure was the economic stress in Venezuela, which prompted millions to flee to other countries, where they began to overwhelm neighboring countries' health care systems.
Azar convened health ministers from across the Western Hemisphere to discuss this matter. Among the solutions: providing medical aid, sending a U.S. navy hospital ship to the region and helping the Pan American Health Organization rebuild the health care system in countries that took in refugees.
Azar and his fellow health ministers also created a vaccine card for migrants.
"Refugees would come out of Venezuela, and they would need to get vaccinated because they have no proof of vaccination or records," Azar says. "You go to Colombia, get vaccinated, but then you migrate up to Panama — and if you don't have proof of vaccination that is reciprocal and recognized, you have to get vaccinated again." This idea of a mutually recognized vaccination card was a simple way to avoid duplicating efforts and contain infectious diseases.
"It's better to solve a problem where it's first identified than waiting for it to have to move," says Azar. "We have a vested interest in trying to make sure that these individuals are healthy."
In more general efforts to aid in vaccination efforts, HHS offers funding and research support — both in the U.S. and abroad — to get vaccines from the lab 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 focus area of HHS is pandemic prevention, from identifying new threats to mounting a comprehensive response.
Shalala, for example, led HHS at the height of the HIV/AIDS pandemic. Her efforts included scaling up NIH funding to discover and test countermeasures to stem the outbreak, ultimately pouring "hundreds of millions of dollars into treatment in other countries," she says. "It was necessary to have an international response at every level, at the treatment level, research level and clinical trial level. Our scientists are internationalists; they don't hold back."
In the mid-1990s, the U.S. covered 40-50% of HIV programs' financing in low-resource countries.
What's more, many of the scientists on the frontlines of the AIDS response were trained by the U.S. "The major contribution, through CDC, is actually the training of a whole generation of public health officers," Shalala says. These local officials are complemented by CDC members who staff over 50 country offices, often working to detect and respond to new outbreaks, and are detailed to multilateral organizations like the World Health Organization as well.
"Diseases don't know what borders they're crossing, and we need to be in strategic places with our expertise to collaborate with the rest of the world," Shalala says.
This mandate also involves building and strengthening public health laboratories to watch out for disease trends as well as guide containment efforts.
When a disease-fighting infrastructure isn't yet in place, HHS can jump in during an outbreak to build it. For example, starting in 2018, there was a large Ebola outbreak in eastern Democratic Republic of the Congo, a an unstable region with a decades-long history of conflict and over 120 militias and armed groups operating in the region. "You have literally no public health infrastructure, you've got a devastatingly poor country, you have really limited civil service and government that's functioning in the area," Azar says. "Cases kept spreading and spreading."
HHS helped coordinate the response, expanding access to rapid diagnostic tests, helping run vaccine and therapeutic clinical trials 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.
One notable challenge was that the local population saw Ebola treatment centers as places where patients went to die. So, HHS staff — and Azar himself — met with faith, community and tribal leaders to show them that, with new antivirals, people could enter these centers and walk out cured. With this surge of support, this Ebola outbreak was stamped out in July 2020. "For other reasons, very few people noticed 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, the anthrax attacks and concern about bioterrorism and chemical agents, there was real concern about how do we link up the world together to coordinate and mitigate against these threats," says Azar.
As a result, President Bush ramped up efforts in global health diplomacy, such as launching the U.S. President's Emergency Plan for AIDS Relief. Since its inception in 2003, this program has invested over $110 billion in the global HIV/AIDS response and been credited with saving over 25 million lives. The State Department is the primary arm of the U.S. government working on both these programs, but HHS contributes scientific expertise and support. (This past week, PEPFAR funding was put on hold for 90 days as part of an executive order affecting foreign aid.)
Beyond direct assistance, the U.S. also leads by example. NIH, the CDC and the FDA, all part of HHS, have served as models across the world, Shalala says. For example, China CDC, Africa CDC and European CDC were modeled off the American agency, and the U.S. worked with these governments to help them establish their organizations.
When countries don't have their own drug approval processes, they often turn to the FDA. "They simply accept the FDA, which is the gold standard," Shalala says. In other words, if the FDA approves a new drug as safe, many other countries will accept that ruling and allow the drug to be distributed.
HHS has also played a leading role during the COVID pandemic. Azar chaired the council of G7 Health Ministers in 2020, who met almost weekly to coordinate a joint response: "sharing learnings, what we're seeing, what different countries are trying, what interventions are being implemented," he says.
Experts predict a different HHS philosophy whether RFK Jr. or another candidate leads the department. The Trump administration is likely to be more isolationist and focused on national self-interest when it comes to global health, predicts Jennifer Kates, director of the Global Health & HIV Policy Program at KFF. The questions she expects to hear over the next four years: "Why are we investing this money? What is it giving America? Are we giving to institutions and countries that align with our interests?"
Simar Bajaj is an American journalist who has previously written for The Atlantic, TIME, The Guardian, Washington Post and more. He is the recipient of the Foreign Press Association award for Science Story of the Year and the National Academies award for Excellence in Science Communications.
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